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CONTENTS

PART I - CLINICAL CASES


1. HISTORY TAKING AND SYMPTOMATOLOGY

1. Weight loss 2 24. Heart burns 5


2. Weight gain 2 25. Vomiting 6
3. Anorexia 2 26. Hematemesis 6
4. Fever 2 27. Constipation 6
5. Chest pain 2 28. Flatulence 6
6. Dyspnea 3 29. Diarrhea 6
7. Cough 3 30. Bleeding per rectum 6
8. Hemoptysis 3 31. Jaundice 6
9. Palpitations 3 32. Epistaxis 6
10. Syncope 3 33. Bleeding Gums 6
11. Polyuria 3 34. Hoarse Voice 7
12. Pyuria 4 35. Itching 7
13. Frequency of Micturition and Nocturia 4 36. Hirsutism 7
14. Hesitancy and Precipitancy of Urine 4 37. Gynecomastia 8
15. Retention of urine 4 38. Backache 8
16. Hematuria 4 39. Hiccough 8
17. Anuria 4 40. Headache 8
18. Pain in the Loin 5 41. Tinnitus 9
19. Abdominal Pain 5 42. Tingling and Numbness 9
20. Dysphagia 5 43. Cramps 9
21. Water brash 5 44. Intermittent Claudication 9
22. Indigestion 5 45. Vertigo 9
23. Eructation 5

2. GENER AL EXAMINATION
1. Built 10 11. Skin and its Appendages 27
2. Body Proportions 14 12. Vertebral Column 31
3. Nutrition 14 13. Thickened nerves 32
4. Decubitus 15 14. Joints 32
5. Clubbing 15 15. Temperature 36
6. Cyanosis 16 16. Pulse 39
7. Jaundice 19 17. Jugular Venous Pulse (JVP) 43
8. Pallor 22 18. Blood pressure 46
9. Lymphadenopathy 23 19. Hypertension 48
10. Edema 25 20. Hypotension 53
3.ABDOMEN

1. Proforma 55 10. Alcoholic Liver Disease 87


2. Examination 56 11. Malaria 90
3. Hepatomegaly 65 12. Kala Azar 95
4. Splenomegaly 67 13. Typhoid 98
5. Ascites 70 14. Leukemia 102
6. Abdominal Lump 72 15. Malignant lymphoma 106
7. Acute Viral Hepatitis 77 16. Human Immunodeficiency Virus (HIV)
8. Cirrhosis of Liver 82 Disease Acquired Immune Deficiency
Syndrome (AIDS) 109
9. Portal Hyp ertension 84

4. RESPIRATORY SYSTEM
1. Proforma 122 10. Chronic Obstructive Pulmonary Disease
2. Examination 124 (COPD) (Emphysema and Chronic
Bronchitis) 168
3. Pleural Effusion 135
11. Pneumonia 172
4. Collapse / Atelectasis of Lung 143
12. Bronchiectasis 175
5. Pulmonary Fibrosis /
Interstitial Lung Diseases 145 13. Lung Abscess 178

6. Pneumothorax 149 14. Solitary Pulmonary Nodule (SPN) 180

7. Pulmonary cavity 154 15. Obstructive Sleep Apnoea 182

8. 16. Hepatopulmonary Syndrome 185


Bronchogenic Carcinoma 155
9. Pulmonary Tuberculosis 158 17. Allergic Bronchopulmonary Asperigillosis
(ABPA) 187

5. CARDIOVASCULAR SYSTEM
1. Proforma 188 12. Cyanotic Congenital Heart Disease 243
2. Examination 189 13. Patent Ductus Arteriosis (PDA) 250
3. Rheumatic fever 203 14. Ventricular Septa! Defect (VSD) 252
4. Infective Endocarditis 205 15. Atrial Septa! Defect (ASD) 253
5. Ischemic Heart Disease 208 16. Coarctation of Aorta 255
6. Cardiac Failure 220 17. Aneurysm of Aorta 257
7. Mitra! Stenosis (MS) 225 18. Pericardia! Effusion 259
8. Mitral Regurgitation (MR) 232 19. Cardiomyopathy 260
9. Mitra! Valve Prolapse (MVP) 236 20. Fitness for surgery
10. Aortic Regurgitation (AR) 237 (Pre-operative Evaluation) 263

11. Aortic Stenosis (AS) 241


6. CENTRAL NERVOUS SYSTEM
I. Proforma 264 8. Myasthenia Gravis 340
2. Examination 266 9. Cerebellum 341
3. Cranial Nerves 298 10. Tuberculosis of Nervous System 344
4. Bulbar Palsy 321 11. Cerebrovascular Diseases 349
5. Hemiplegia 322 12. Parkinsonism 357
6. Paraplegia 326 13. Coma 365
7. Quadriplegia 336 14. Syphilis of Nervous System 370

PART II-TABLE-WORK
7. MEDICAL EMERGENCIES
1. Cardiac Arrest 374 28. Acute Retention of Urine 395
2. Cardiac Failure 377 29. Acute Renal Failure (ARP) 395
3. Ischemic Heart Disease 377 30. Diabetic Ketoacidosis 396
4. Stokes Adams Syndrome 377 31. Hypoglycemia 397
5. Hypertensive Crisis 377 32. Respiratory Acidosis 398
6. Hypertensive Encephalopathy 378 33. Metabolic Acidosis 399
7. Shock 379 34. Respiratory Alkalosis 399
8. Anaphylactic Shock 380 35. Metabolic Alkalosis 399
9. Pulmonary Embolism and 36. Dehydration 400
Deep Vein Thrombosis 380 37. Hypernatremia 400
10. Hemoptysis 382 38. Hyponatremia 400
11. Bronchial Asthma 383 39. Hyperkalemia 401
12. Respiratory Failure 385 40. Hypokalemia 401
13. Tension Pneumothorax 386 41. Acute Hypercalcemia 401
14. Hematemesis 387 42. Amebic Dysentery 401
15. Acute Gastroenteritis / Food poisoning 388 43. Bacillary Dysentery 402
16. Acute Pancreatitis 389 44. Cholera 402
17. Hepatic Coma 389 45. Typhoid 403
18. Coma 390 46. Dengue 403
19. Meningitis 390 47. Leptospirosis 404
20. Cerebrovascular Diseases 391 48. Diphtheria 405
21. Subarachnoid Hemorrhage 391 49. Tetanus 405
22. Epilepsy 391 50. Rabies 406
23. Sickle Cell Crisis 393 51. Cerebral Malaria 406
24. Acute Hemolytic Crisis 393 52. Acute Poisonings 406
25. Aplastic Anemia 394 53. Organophosphorous Compound
26. Hemophilia 394 Poisoning 407
27. Renal Colic 394 54. Acute Alcoholic Intoxication 408
55. Barbiturate Poisoning 408 59. Snake Bite 410
56. Acute Salicylate Poisoning 409 60. Scorpion Bite 411
57. Carbon Monoxide Poisoning 409 61. Hyperpyrexia 413
58. Carbon Dioxide Narcosis 410 62. Drowning 413

8. ELECTROCARDIOGRAPHY
1. Introduction 415 6. Rhythm Disturbances 422
2. Normal ECG 415 7. Conduction Defects Atrioventricular
3. Waves and Complexes 416 Block (AV Block) 429
4. Myocardial Infarction 421 8. Effect of Drugs and Electrolytes 430
5. Ventricular Enlargement 421

9. RADIOLOGY
1. X-ray chest 432 5. Barium studies 443
2. X-ray Chest - Heart 437 6. X-ray of Bones 447
3. Plain X-ray Abdomen 438 7. X-ray Skull 452
4. Urogenital System 440

10. INSTRUMENTS
1. Endotracheal Tube 455 20. Urosac Bag 465
2. Tracheostomy Tube 456 21. Stomach Tube 466
3. Laryngoscope 457 22. Ryle's Tube (RT) or Nasogastric Tube 466
4. Oxygen Mask and Oxygen Cannula 23. Sengstaken Blakemore Tube (S.B. Tube) 467
(Nasal Prongs) 458 24. Infant Feeding Tube 468
5. Nebulizer Chamber 458 25. Record Syringe and Needle 469
6. Metered Dose Inhaler 458 26. B.D. Syringe and Needle 469
7. Spacehaler 459 27. Tuberculin Syringe 470
8. Rotahaler 459 28. Insulin Syringe 470
9. Nelson's Inhaler 459 29. Lumbar Puncture Needle 471
10. Ambu Bag (Self-inflating Ventillation Bag) 460 30. Cisternal Puncture Needle 471
11. Airway 460 31. Vim-Silverman's Needle 471
12. Mouth Gag 461 32. Menghini's Needle and Syringe 471
13. Tongue Depressor 462 33. Bone Marrow Aspiration Needle 471
14. Trocar and Cannula 462 34. Pleural Biopsy Needle 472
15. Asepto Syringe and Bulb 462 35. Trucut Needle 472
16. Simple Rubber Catheter 462 36. Southey's Tube and Needle 472
17. Foley's Self-retaining Catheter 463 37. Tourniquet 472
18. Malecot's Catheter 465 38. Venesection Needle 473
19. Condom Catheter 465 39. Scalp Vein Needle 473
40. Pleural or Ascitic Aspiration Needle 473 44. Clinical Thermometer 475
41. Intravenous Cannulas 45. Flatus Tube 476
(Venflow or Angiocath) 473 46. Proctoscope 476
42. Three Way 474 47. Stethoscope 477
43. I.V. Set 474 48. Central Venous Catheter 477

11. PROCEDURES
1. Transvenous Pacing 479 11. Ascitic Tapping 490
2. Cardioversion 479 12. Gastric Analysis 491
3. Lumbar Puncture 480 13. Glucose Tolerance Test (G.T.T.) 492
4. Cisternal Puncture 484 14. Intravenous Therapy 493
5. Liver Biopsy 484 15. Subcutaneous Infusions 495
6. Kidney Biopsy 486 16. Tracheostomy 495
7. Bone- marrow Aspiration 487 17. Oxygen Therapy 496
8. Pleural Fluid Aspiration 488 18. Enema 497
9. Aspiration ofPneumothorax Cavity 489 19. Parenteral Hyperalimentation 499
10. Pericardia! Aspiration 490

12. HEMATOLOGY
1. Blood Collection 501 11. Electronic Cell Counters 514
2. Preparation ofBlood 502 12. Red Cell Indices 514
3. Hemoglobin Estimation 505 13. Red Cell Morphology 515
4. Packed Cell Volume (PCV ) 507 14. Anemias 517
5. Erythrocyte Sedimentation Rate (E.S.R.) 507 15. Differential Leucocyte Count 522
6. Reticulocyte Count 509 16. Leukemias 525
7. Osmotic Fragility ofRBCs 510 17. Parasites in Blood 525
8. Total Red Cell Count 510 18. Multiple Myeloma 526
9. Total White Cell Count 511 19. Coagulation studies 526
10. Platelet Count 513 20. Normal Hematological Values 613

13. CLINICAL PATHOLOGY


1. Urine Examination 533 3. Feces Examination 539
2. Sputum 539 4. Helminthic Infections 541

14. PATHOLOGY SP ECIMENS


1. Central Nervous System 546 5. Large Intestines 553
2. Cardiovascular System 547 6. Liver 553
3. Lung 549 7. Kidney 555
4. Small Intestine 552

L_
15. DRUGS
1. Cardiovascular Drugs 557 5. Antibacterial Agents 585
a) Inotropic Drugs 557 a) Sulfonamides 585
b) Anti-arrhythmic Drugs 558 b) Quinolones 586
c) Anti-angina! Agents 560 c) Beta-lactams 586
d) Anti-hypertensive Agents 561 d) Macrolides 588
e) Anti-thrombotic Agents 566 e) Aminoglycosides 589
e) Heparins/Aprotinin 566 f) Tetracyclines 589
f) Diuretics 567 g) Chloramphenicol 590
2. Autonomic Nervous System 568 6. Anti-tuberculous Drugs 590
a) Catecholamines 568 7. Anti-leprosy Drugs 591
b) Cholinergic and Anti-cholinergic Agents 569
8. Anti-amoebic Drugs 592
3. Drugs in Respiratory Diseases 570
9. Drugs for Kala- azar 593
a) Anti-asthma Agents 570
b) Agents for Cough and Expectoration 572 10. Anti-malarial Drugs 593
c) Anti-allergic Drugs 572 11. Anti-helminthic Agents 594
d) Serotoninergic Agents 573 12. Anti-fungal Agents 597
4. Drugs in Central Nervous System 13. Anti-viral Agents 598
Diseases 573
a) Opioids 573 14. Anti-retroviral Agents for HIV Infection 599
b) Analgesics and Anti-inflammatory Drugs 574 15. Alcohol 601
c) Drugs in Migraine 576 16. Anti-malignancy Agents 601
d) Drugs in Gout and Arthritis 576
17. Hemopoietic Drugs 603
e) Anti-epileptic Drugs 577
f) Muscles Relaxants 579 18. Chelating Agents 604
g) Anti-psychotic Drugs 579 19. Drugs in Endocrine Disorders 605
h) Sedatives / Hypnotics 580 20. Drugs for Diabetes 607
i) Anti-depressants 582
21. Lipid Lowering Agents 608
j) Anti-parkinsonism Drugs 583
k) Drugs in Stroke 584 22. Gastro-intestinal Drugs 609
I) Drugs in Degenerative Brain Disorders 584 23. Electrolytes 611
25. Plasma Expanders 612

List of Contributors for the 20th Edition

Dr. Hardik Shah Dr. Sunita Iyer Dr. Nikesh Jain Dr. Rajiv Shah
H
istory taking is an art, which a doctor learns with their time ofoccurrence, duration and results
over the years by repeated practice and ex­ should be noted. Childhood illnesses (eruptive
perience. History is the record of medical fevers, per tussis, influenza), tuberculosis,
events that have already taken place in the patient. diabetes, hyp ertesnion, asthma, heart disease,
Since every disease has a pattern of behavior, a good jaundice, joint swelling, etc. must be inquired into.
history combined with a sound knowledge of medicine Past injuries, accidents, operations or hospital
would help the doctor to judge the likely cause(s) that stay and blood transfusion history must also be
may be responsible for the patient's problems. In over noted in details.
80% cases the most likely diagnosis can be reached 5. Personal history: Patient's appetite, food habits,
by a proper history. On clinical examination, the type of diet, bowel and micturition habits, sleep
clinical state of the patient is determined at that given and addictions like alcohol, smoking, tobacco
time. However, nothing is usually known of the past chewing, charas, ganja, marijuana etc., must
problems. Hence, without an appropriate history, an be inquired into. Loss of appetite and weight
incorrect interpretation of the physical findings may may suggest an active disease process. Similarly
be made. E.g. a person has brisk reflexes and extensor improper sleep due to other symptoms would
plantar: a recent history of transient ischemic attack suggest that those symptoms require urgent
would suggest recent stroke, whereas an old history attention. Alcohol, tobacco, smoking and other
of stroke a few years ago would suggest residual effect intoxicants can adversely affect many systems
of a past stroke. in the body and the role of these substances in
A good history must record the following information the patient's problems can be easily judged by
in a systematic order. the history. E.g. alcohol may be responsible for
1. Biodataofthe patient: This should include name, liver cell failure and cirrhosis as well as acute
age, sex, address, occupation, religion and marital gastritis. Heavy smoking may be responsible
status of the person. for precipitating coronary artery disease or
hypertension in the young.
2. Complaintsofthepresentillness: The complaints
with which the patient has come should be 6. Family history: Any illness in the family must
recorded in chronological order and the duration be recorded. The state of health of parents, peers
should be noted. and children should be noted. If any member is
deceased, the cause of death should be noted.
3. Origin, duration and progress: Details of each
Some genetically transmitted diseases are:
symptom must be recorded separately. The mode
of onset, whether sudden or gradual, the duration a. X-linked recessive diseases (e.g. Duchenne
of each symptom and its progress and finally the muscular dystrophy, hemophilia, G6PD
present status of the symptom must be noted. deficiency, ichthyosis). Women are carriers
Associated symptoms must also be inquired into and do not suffer from the disease, whereas
and recorded. males suffer from the disease. Hence, in such
illnesses, the family history would suggest
4. History of past illness: Similar illness in the past
similar illnesses in the patient's brothers,
PRACTICAL MEDICINE

sister's sons, mother's brother and mother's


sister's sons. 2 > Weigc.___ht_ G_ai__
n __
_ _
b. Autosomal dominant disorders ( e.g. 1. Increased water retention: Cardiac failure,
familial hyperlipidemias, polycystic kidney, cirrhosis of liver, nephrotic syndrome,
Huntington's disease, neurofibromatosis, hyp oproteinemia, edema states, etc.
congenital spherocytosis, myotonia 2. Increased tissue mass:
dystrophica). There will be a family history a) Obesity
of similar illness in either of the parents and/
b) Endocrine diseases: Cushing's disease,
or grandparents.
hyp othyroidism, acromegaly, etc.
c. Autosomal recessive disorders (e.g. beta
c) Hypothalamic diseases: Craniopharyngi-oma,
thalassemia, sickle cell anemia, spinal
Frohlich's syndrome, hamartoma, etc,
muscular dystrophy, phenylketonuria, cystic
fibrosis, congenital adrenal hyperplasia). d) Drugs: e.g. steroids
There is usually no history of similar illness

3 > Anorexia
in the parents since they may be heterozygous
and hence only carriers. However, history
of consanguineous marriage in the parents 1. Viral hepatitis including anicteric hepatitis
(marriage between cousins or brother and
2. Tuberculosis
sister or uncle and niece) may be present and
may be responsible for the homozygous state 3. Carcinoma of stomach and other malignancies
in the patient and thus the manifestation of 4. Endocrine diseases: Addison's disease,
the disease. panhypopituitarism
7. Menstrual and obstetric history: In females, 5. Chronic wasting diseases: Uremia, cirrhosis of
the date of onset of menstruation, date of last liver, chronic alcoholism, chronic smoking etc.
menstruation and the amount of blood flow, 6. Drugs: Digitalis, quinine, metronidazole, etc.
regularity and pain during menstruation should
be noted. In a woman who has conceived, details
of past abortions, premature births and normal 4 Fever
or abnormal deliveries should be noted.
(Refer Pg. 36: Temperature)
Some of the common symptoms which the patients
present with and their causes are given below:
5 > Chest Pain
1
- -
Weight
- Loss 1. Cardiac: Ischemic heart disease, pericarditis,
1. Caloric malnutrition: Fasting, inappropriate diet infective endocarditis, cardiomyopathy, valvular
heart disease, dissecting aneurysm of aorta, etc.
2. Infections (chronic): Infective endocarditis,
tuberculosis, amebic liver abscess, fungal 2. Respiratory: Pleurisy, pneumothorax, pulmonary
infections, H.I.V. infection, etc. embolism, pulmonary hypertension, malignancy
3. Acute infections: Viral hepatitis, typhoid, 3. Musculoskeletal: Rib fracture, vertebral collapse,
septicemia costochondritis, myositis of pectoral muscle, etc.
4. Malignancy 4. Functional
5. Malabsorption syndrome 5. Miscellaneous: Herpes zoster of intercostal
6. Endocrine diseases: Diabetes m ellitus, nerves, esophagitis, pancreatitis, peptic ulcer,
thyrotoxicosis, panhyp opituitarism, Addison's cholecystitis, splenic flexure syndrome, etc.
disease, etc.
7. Anorexia nervosa
2
( 1 > History Taking and Symptomatology

6>D s nea B>Hemop�ysi�


� s_ _
_ _
1. P hysiological: Mountaineers, exercise, (Refer Pg. 382)
hyperpyrexia, anemia

9 > Palpitations
2. Respiratory: Airway obstruction, bronchial
asthma, chronic obstructive lung disease,
pulmonary infections, pulmonary edema, 1. Physiological: Exercise, emotional or sexual
pulmonary embolism, bronchogenic carcinoma, excitement, etc.
pleural effusion, pneumothorax, etc.
2. Excessive tea, coffee, tobacco, alcohol
3. Cardiac: Acute myocardial infarction, valvular consumption
heart disease, left ventricular failure, congenital
3. Anxiety state
cyanotic heart disease, etc.
4. High output state: Anemia, beriberi,
4. Metabolic: Diabetes, uremia, hypokalemia
thyrotoxicosis, A-V fistula, Paget's disease, etc.
5. Neurological: Respiratory center depression as
5. Cardiac arrhythmia: Extrasystoles, paroxysmal
in syringobulbia, motor neuron disease, Guillain
tachycardia, atrial fibrillation, heart block, etc.
Barre syndrome, bulbar polio, myasthenia gravis
6. Drugs: Sympathomimetic agents, nitrates,
6. Psychogenic
overdose of digoxin or insulin
(For ATS Dyspnea Scale: Refer pg. 125)
7. M i s ce l l a n e o u s : P h e o c h r o m o c y to m a ,
(For NYHA Classification: Refer pg. 211) hypoglycemia, etc.

7>Coug�
-
h �-
- - -
� 1 O > si_n_co__.p_e___
1. Respiratory: 1. Vasovagal syncope
a. Laryngeal and pharyngeal infections and 2. Postural hypotension
neoplasms
3. Cardiac arrhythmia: Stokes Adam's syndrome
b. Tracheobronchial: Tracheobronchitis, bronchial
4. Stenotic lesions of the heart: Aortic stenosis,
asthma, bronchiectasis, bronchogenic
hypertrophic subaortic stenosis, pulmonary and
carcinoma, pressure over the trachea and
mitral stenosis, Fallot's tetrad, ball valve thrombus
bronchus from outside, aspiration, etc.
in left atrium.
c. Lung: Pneumonia, tuberculosis, lung abscess,
5. Cerebrovascular insufficiency: Vertebrobasilar
tropical eosinophilia, pulmonary edema and
insufficiency, carotid sinus syncope, etc.
infarction, interstitial fibrosis, etc.
6. Miscellaneous: Massive myocardial infarction,
d. Pleural: Pleural effusion, pneumothorax, etc.
pericardial tamponade, left atrial myxoma,
2. Cardiac: Left ventricular failure, mitral stenosis, micturition syncope, cough syncope, internal
aneurysm of aorta, etc. bleeding, etc.
3. Mediastinum: Enlarged lymph nodes, mediastinal

11 > Poli�u.:...:
tumors, etc.
4. Psychogenic ri-=- a____ _
_
5. Reflex: Wax or foreign body in the ear, subphrenic 1. Transient: Excessive water drinking, diuretic
or liver abscess, etc. therapy, cold weather, stress
2. Persistent:
a. Diabetes mellitus

3
PRACTICAL MEDICINE

b. Diabetes insipidus (pituitary and nephrogenic)


15 > Retention of Urine
c. Renal: Chronic renal failure, recovery from
acute tubular necrosis, analgesic abuse I. Neurological: Spinal cord diseases (transverse
nephropathy, etc. and compression myelitis), cauda equina lesions,
multiple sclerosis
d. Compulsive water drinking
2. Genitourinary:

12 > P}f_u_ri_a ______


a. Penis: Phimosis
b. Urethra: Posteriorurethral valves, foreign body,
1. Renal: stones, stricture, rupture, spasm of sphincter,
etc.
a. Infective: Pyelonephritis, pyonephrosis,
perianal abscess, renal tuberculosis c. Prostatic enlargement

b. Non-infective: Hypersensitivity nephritis, d. Bladder: Atony, tumour, stone, or compression


analgesic nephropathy, hypo kalemia, by fibroids or retroverted uterus.
nephrocalcinosis, lead poisoning, radiation e. Following parturition.
nephritis 3. Drugs: Sympathomimetic agents, salbutamol,
2. Lower urinary tract: terbutaline, anticholinergic drugs, etc.
a. Cystitis: Infective, radiation, cytotoxic drugs 4. Functional
b. Urethritis
3. Adnexa: Perinephric abscess, gynecological
infections
16 > Hematuria
1. Renal: Glomerulonephritis, renal infarction,

13 > Frequency of
stones, tumors, tuberculosis, interstitial
nephritis, papillary necrosis, polycystic
Micturition and kidneys, etc.
Nocturia 2. Ureteric: Trauma, tuberculosis, stones, neoplasms
3. Bladder: Trauma, tuberculosis, stones, neoplasms,
1. Bladder: Cystitis, small contracted bladder,
cystitis, following cyclo-phosphamide therapy
tumors, vesicular calculus, cystocele
4. Urethral: Trauma, stones, foreign body, urethritis
2. Bladder neck: Incomplete evacuation due
to enlarged prostate or stricture of urethra, 5. Prostatic: Prostitis, neoplasms
incompetent internal urethral sphincter, ectopic 6. Systemic diseases: Diabetes, amyloidosis,
ureter collagen disease, DIC, etc.
3. Urethra: Urethritis, neoplasms, balanitis, stricture

17 > Anuria
of urethra, pinhole meatus, phimosis
4. Miscellaneous: Polyuria, psychogenic, pregnancy,
pressure from surrounding structures 1. Renal: Glomerulonephritis, pyelonephritis,
polycystic kidney, chronic renal failure,

14 > Hesitancy and


nephrotoxic drugs, SLE etc.
2. Pre-renal: Diarrhea and vomiting, burns, blood
Precipitanci of Urine loss, hypotension, septicemia, intravascular
hemolysis, etc.
1. Cerebral: Cerebrovascular accidents, cerebral
3. Obstructive: Calculi in kidney or urinary tract,
tumors, head injuries, etc.
blockage of ureters by malignancy or crystals,
2. Urinary tract disease: Enlarged prostate, bladder retroperitonealfibrosis, accidental ligation during
neck obstruction surgery, etc.
4
( 1 ) History Taking and Symptomatology

18 > Pain in the Loin 21 > Water Brash


1. Renal: Stone, malignan c y, infections 1. Normal individuals following heavy meals
(pyelonephritis, perinephric abscess, etc.), 2. Incompetent lower esophageal sphincter
polycystic kidney, Dietl's crisis, etc.
3. Peptic ulcer disease
2. Extrarenal: Acute pancreatitis, cholecystitis,
4. Biliary tract disease
appendicitis, porphyria, ruptured duodenal ulcer
or spleen, ectopic gestation, etc.
22 > lndi estion
19 > Abdominal Pain 1. Upper gastrointestinal tract: Alcohol, following
heavy meals, aerophagia, hiatus hernia,
1. Acid peptic disease
gastroesophageal reflux, peptic ulcer disease,
2. Peritonitis gastritis, drugs, etc.
3. Mechanical obstruction of hollow viscus 2. Lower gastrointestinal tract: Parasites, Food
4. Colic: Intestinal, renal, biliary, etc. intolerance, irritable bowel syndrome, increased
5. Vascular disturbances producing ischemia and intraluminal gas, etc.
abdominal angina: Thromboembolism, sickle cell 3. Hepatobiliary: Cholecystitis, stones, pancreatitis,
crisis, rupture of aneurysm, etc. splenic flexure syndrome, etc.
6. Abdominal wall: Fatty hernia through linea alba, 4. Systemic diseases: Uremia, cardiac failure,
trauma or infection of the muscle etc. tuberculosis, malignancy
7. Referred pain: Pneumonia, pleurisy, ischemic 5. Functional
heart disease, panniculitis, torsion of the testes

23 > Eructation
or ovary.
8. Metabolic: Diabetes, uremia, porphyria, lead
poisoning, Henoch Schonlein purpura 1. Faulty dietary habits: Aerated water, chewing
9. Neurogenic: Herpes zoster, tabes dorsalis, etc. gum, mouth breathing, etc.
10. Functional 2. Addiction: Smoking, alcohol, betel nut, pan, etc.
3. Gastrointestinal: Gas tritis, peptic ulcer,

20 > Dysphag ia
hiatus hernia, cholecystitis, stones, irritable bowel
syndrome
1. Esophageal: Inflammation, webs, strictures, 4. Psychogenic: Anxiety, depression, etc.
tumors, achalasia cardia, spasm, hiatus hernia,

24 > Heart Burns


Chagas' disease, scleroderma, radiation, etc.
2. Upper gut: Pharyngeal and laryngeal lesions
3. External compression: Cervical spondylitis, 1. Organiclesions: Refluxesophagitis, hiatus hernia,
retropharyngeal abscess, goitre, enlarged left peptic ulcer, etc.
atrium, aneurysm, etc. 2. Functional: Faulty dietary habits, addictions, etc.
4. Neurological: Bulbar palsy, polyneuropathy, 3. Psychogenic: Neurosis, repressed emotions etc.
motor neuron disease, myopathies, myasthenia,
dermatomyositis.

5
PRACTICAL MEDICINE

25 >Vomitin 28 > Flatulence


1. Abdominal: 1. Gastric: Aerophagy, neurosis, gastric or
a. Gastritis and Peptic ulcer biliary disease (hiatus hernia, pyloric stenosis,
b. Colic biliary dyspepsia), following vagotomy etc.

c. Acute abdominal emergencies: Appendicitis, 2. Food intake: Cabbage, cauliflower, peas,


cholecystitis, peritonitis, pancreatitis, beans, etc.
intestinal obstruction, etc. 3. Intestinal: Steatorrhea, intestinal obstruction,
2. Cardiac: Myocardial infarction, cardiac failure, malignancy, etc.
etc. 4. Systemic diseases: Cardiac failure, cir�hosis, etc.
3. Central: Raised intracranial tension, Meniere's

29 > Diarrhea
disease, motion sickness, radiation, etc.
4. Metabolic: Diabetes, alcohol, pregnancy,
hypercalcemia, Addison's disease 1. Osmotic: Laxative abuse, maldigestion of food
5. Toxic: Febrile illnesses (viral hepatitis), cholera, 2. Infections: Typhoid, cholera, amebiasis,
drugs (salicylates), corrosive poisons giardiasis, helminthiasis, H.I.V. infection, etc.
6. Functional 3 Endocrine diseases: Thyrotoxicosis, diabetes,
Addison's disease, etc.

26 > Hematemesis
4. Drugs: Thyroxine, prostigmin, ampicillin,
_ phenolphthalein, etc.
5. Anxiety: Irritable bowel syndrome, etc.
(Refer Pg. 387)
6. Miscellaneous: Malignant carcinoid syndrome.

27 > Consti
30 > Bleeding Per Rectum
1. Acute:
1. Anal: Fissure, fistula, foreign body, etc.
a. In t e s t i n a l o b s t r u c t i o n : Vo l v u! u s ,
intussusception, hernia, etc. 2. Rectal: Piles, proctitis, foreign body, neoplasms
3. Colonic: Bacillary and amebic dysenter y,
b. Acute abdomen: Appendicitis, salpingitis,
ulcerative colitis, carcinoma, polyps, diverticula,
perforation, colic, etc.
ischemia, irritant drugs, etc.
c. General: Septicemia
4. Hematological: Blood dyscrasias, anti-coagulant
2. Chronic: therapy, uremia, etc.
a. Faulty habits: Laxative abuse, prolonged travel,

> Jaundice
insufficient dietary roughage, etc.
b. Painful anal conditions: Piles, fissures, etc. 31
c. Organic obstruction: Carcinoma, diverticulum, (Refer Pg. 19)
strictures, etc.

32 > Epistaxi_s_
d. Adynamic bowel: Scleroderma, myopathies,
myotonia, etc.
e. Metabolic: Hypothyroidism, hypokalemia, 1. Hematological:
hypercalcemia, porphyria, lead poisoning a. Thrombocytopenia: ITP, leukemia, aplastic
f. Drugs: Atropine group, opium group, tricyclic anemia, etc.
antidepressants, coffee, etc.

6
( 1 ) History Taking and Symptomatology

b. Qualitative platelet defects: Glanzmann's


thrombasthenia, von Willebrand's disease, etc. 34 Hoarse Voice
c. Coagulation disorders: Hemophilia, 1. Local: Singer's nodules, laryngitis, foreign body,
afibrinogenemia, etc. tumours of larynx.
d. Miscellaneous: Hypersplenism, vitamin B 12 2. Recurrent laryngeal nerve palsy
deficiency, etc. 3. Systemic diseases: Myxedema, angioneurotic
2. Nasal diseases: Trauma, tumors, rhinitis, edema, etc.
diphtheria, sinusitis, etc. 4. Toxic: Tobacco, alcohol
3. Systemic diseases:

35 Itching_
a. Infective fevers: Typhoid, malaria, measles,
viral infections, etc.
b. Hypertension 1. Skin disease: Scabies, candidiasis, psonas1s,
c. High altitude urticaria, pediculosis, allergic dermatitis, dry skin
d. Collagen disease: Pseudoxanthoma elasticum, 2. Systemic diseases:
Ehlers' Danlos syndrome, etc. a. Drug reaction
b. Senile purpura

33 > Bleeding'---
Gums
-
- -------
c. Infections: Enterobius vermicularis, hook­
worm, tinea infections, hydatid cyst, etc.
1. Hematological: d. Endocr ine diseases: Diabetes mellitus,
a. Thromboc ytopenia: Leukemias, aplastic hyp othyroidism, hepatic diseases, obstructive
anemia, ITP, etc. jaundice, primary biliary cirrhosis, etc.
b. Qualitative platelet defect: Glanzmann's e. Renal diseases: Chronic renal failure, etc.
thrombasthenia, von Willebrand's disease, f. Blood diseases: Polycythemia vera, malignancy,
giant platelet syndrome, etc. Hodgkin's disease, myeloma, etc.
c. Coagulation disorders: Hemophilia, Christmas 3. Pregnancy
disease, vitamin K deficiency, afibrinogenemia,

36 > Hirsutism
anticoagulants, etc.
d. Miscellaneous: Hypersplenism, vitamin
B 12 deficiency, disseminated intravascular I. With virilization: Arrhenoblastoma, malignant
coagulation, etc.
adrenal tumors, congenital adrenal hyp erplasia,
2. Gum diseases: Gingivitis, periodontitis, herpes, testicular tumors, etc.
Vincent's infection
3. Systemic disease:
a. Scurvy
b. Drugs: Phenytoin therapy
c. Diabetes mellitus, Cushing's syndrome
d. Pregnancy
e. Henoch-Schonlein purpura
f. Connective tissue disease: Ehlers' Danlos
syndrome, etc.

7
PRACTICAL MEDICINE

2. Without virilization: 3. Infection: Osteomyelitis, tuberculous spine (Pott's


a. Familial spine)
b. Idiopathic 4. Neoplastic: Primary tumors, secondaries,
c. Polycystic ovarian syndrome multiple myeloma, etc.
d. Acromegaly, Cushing's syndrome, HAIR-AN 5. Metabolic: Osteoporosis, osteomalacia,
syndrome, congential adrenal hyp erplasia hyp erparathyroidism, renal stones, etc.
e. Drugs: Androgens, phenytoin sodium, 6. Congenital: Spina bifida
minoxidil 7. Arthritis: Rheumatoid arthritis, osteoarthritis,
ankylosing spondylitis, etc.

37 > _&�necomastia_
8. Referred pain: Pancreatitis, retroperitoneal
tumors, cholecystitis, diverticulitis, retroverted
1. Physiological: During infancy and at puberty uterus, uterine prolapse, etc.
2. Refeeding: Recovery from wasting diseases 9. Spinal deformities: Kyphosis, scoliosis and
3. Testicular: Agenesis, orchitis, tumour, Klinefelter's lordosis
syndrome, etc.
4. Endocrine: Acromegaly, adrenal tumors, ectopic
hormone production, etc.
39 > Hiccoug<.:_h_____
5. Drugs: Digitalis, spironolactone, phenothiazine, 1. Metabolic: Uremia, diabetes
metoclopramide, cimetidine, etc. 2. Toxemia: Septicemia, high fever
6. Miscellaneous: Cirrhosis of liver, rheumatoid 3. Abdominal: Liver abscess, peritonitis, subphrenic
arthritis, leprosy, etc. abscess, etc.
4. Thoracic: Aortic aneurysm, mediastinal glands,
substernal goitre, etc.
5. Neurological: Encephalitis, meningitis, brain
tumour, etc.
6. Psychogenic: Hysterical, neurosis
7. Epidemic hiccoughs

40 > Headache
1. Intracranial:
a. Meningeal: Meningitis
b. Vascular: Intracranial aneurysm, malignant
hyp ertension, subarachnoid hemorrhage
c. Skeletal: Metastasis, Paget's disease, etc.
d. Space occupying lesion: Subdural hematoma,
tumors, granulomas, abscess

38 > Backache 2.
e. Post lumbar puncture
Extracranial
1. Physiological: Faulty posture, asthenic a. Vascular: Migraine, cluster headache, temporal
individuals, pregnancy arteritis, etc.
2. Trauma: Prolapsed intervertebral disc, b. Skeletal: Paget's disease, torticollis, etc.
lumbosacral strain

8
( 1 ) History Taking and Symptomatology

c. Referred pain: Sinusitis, eyestrain, glaucoma, 3. Neurological: Amyotrophic lateral sclerosis,


aural, etc. muscular dystrophy, myotonia, peripheral
3. Miscellaneous: Psychogenic, posttraumatic, neuritis
alcohol, nitrates, monosodium glutamate 4. Metabolic: Uremia, McArdle's disease
ingestion etc. 5. Occupational: Miners, writers, typists, tailors,
telephone operators, etc.

41 > Tinnitus 6. Miscellaneous: Pregnancy, dehydration, chronic


wasting diseases, overexertion.
1. Auditory:

44 > Intermittent
a. External ear: Wax, polyp, foreign body, etc.
b. Middle ear inflammation
c. Internal ear: Meniere's disease, labyrinthitis,
Claudication
acoustic neuroma 1. Arterial: Atheroma, embolism, Buerger's disease
2. Systemic: Migraine, barotrauma, anemia, aortic 2. Systemic: Diabetes mellitus, syp hilis, anemia,
regurgitation, salicylates, quinine, etc. McArdle's disease, overexertion

42 > Tingling and Numbness 45 > Vertigo


1. Peripheral neuropathy 1. Cerebellar: Cerebellitis, injury, infarction, etc.
2. Ent rapment neuropathy: Carpal tunnel 2. Brain Stem: Vertebrobasilar insufficiency
syndrome, thoracic inlet tumor 3. Vestibular: Neuronitis, acoustic neuroma,
3. Skeletal: Cervical spondylitis, lumbar canal cerebello pontine angle tumour, etc.
stenosis, disc lesion, tumour, etc. 4. Auditory: Acute labyrinthitis, Meniere's disease,
4. Transient toxic effects of alcohol, streptomycin, salicylates,
spread of disease from middle ear, Eustachian

43 > Cram�s
tube blockage
- --- ------ 5. Miscellaneous: Migraine, aura of epilepsy,
1. Idiopathic anemia, hypotension, head injury, etc.
2. Elect rolyte distur bances: Hyponatremia,
hyp ocalcemia, hypomagnesemia

For details refer to P.J. Mehta's "Common Medical Symptoms" 6th Edition, 2013

9
T
he general examination of the patient must 4. Metabolic: Marfan's syndrome, homocystinuria
be done systematically, noting the following: 5. Miscellaneous: Cerebral gigantism, etc.

Differential Diagnosis
1. Built 11. Skin, hair and nails
1. Constitutional: Usually in constitutional tall
2. Body proportions 12. Vertebral column
stature the parents are also tall. In all children
3. Nutrition 13. Thickened nerves whose parents or grand parents are also tall, a
4. Decubitus 14. Joints suspicion of a pathological disorder must be
5. Clubbing 15. Temperature raised. The child is otherwise normal. In boys
usually no treatment is required. In girls long
6. Cyanosis 16. Pulse
term estrogen could be used to suppress further
7. Jaundice 17. Jugular venous growth. However, because of its side-effects,
8. Pallor pulse & pressure usually it is avoided unless the predicted adult
9. Lymphadenopathy 18. Blood pressure height is more than 183 ems.
10. Edema 19. Respiration 2. Gigantism (Acromegaly!Hyperpituitarism): In
gigantism the patient is very tall but with normal
body proportions. However, the features are
1 > Built coarse with increased heel pad thickness. There
may be evidence of raised intracranial tension
Built is the skeletal structure in relation to age and and bitemporal hemianopia. Pituitary tumors
sex of the individual as compared to a normal person. need surgery.
Tall Stature 3. CerebralGigantism(Soto'ssyndrome): Children
with cerebral gigantism have a large elongated
A child is considered to be tall when the height is head, prominent forehead, large ears and jaws,
greater than 2 standard deviations above the mean elongated chin, antimongoloid slant to the eyes
for the age. Gigantism is the term applied when the and coarse facial features. They have subnormal
patient's height is greatly in excess of the normal for intelligence and impaired coordination. The cause
his age before fusion of epiphysis. There is no fixed is not known.
height to constitute a giant, but in adults, it is applied 4. Sexual Precocity and virilizing disorders: In
for individuals with a height of more than 6� ft. these children, acceleration of linear growth
Causes occurs simultaneously with signs of premature
sexual development or inappropriate virilization.
1. Simple or primary gigantism: Racial, familial or This disorder may be due to congenital adrenal
constitutional hyperplasia, adrenal tumor, gonadal tumor or
2. Endocrine: Hyp erpituitarism, hyp ogonadism premature secretion of gonadotropic hormones.
3. Genetic: Klinefelter's syndrome The bone age is usually advanced so that the adult
stature may be diminished.
{ 2 ) General Examination

Table 2.1 : Differential Diagnosis of Gigantism when Upper Segment = Lower Segment
Constitutional Hyperpituitarism Cerebral gigantism

1. Family history +
2. Obesity + +
3. Mental retardation +
4. Otherfeatures OfGigantism Macrocrania, large hands andfeet

5. Post-glucose growth hormone (G.H.) N Increased N

Table 2.2 : Differences between Marfan's Syndrome and Homocystinuria


Marfan's Syndrome Homocystinuria

1. Inheritance Autosomal dominant Autosomal recessive

2. Ectopia lentis Upward dislocation Downward dislocation

3. High arched palate Present Absent

4. Loose jointedness Present Absent

5. Arachnodactyly Strikingly seen Not striking

6. Mental retardation Absent Present

7. Vascular disease Aortic Thrombotic

8. Urine Benedict's test Normal Positive

9. Cyanide Nitroprusside test Absent Cystine and homocystine present

10. Liver biopsy Normal Low activity ofCystathionine synthetase

5. Marjan 's syndrome: These patients are tall Short Stature (Dwarfism)
with long limbs, narrow hands, long slender
Dwarfism is the term applied when the patient's
fingers (arachnodactyly), hyperextensible joints,
height is 2standard deviations less than that for
dislocation of the lens, high arched palate,
his/her age and sex. Mid-parental height usually de­
kyphoscoliosis, arm span greater than the height
termines the final height.
and the lower segmetnt more than the upper
segment. Causes
6. Homocystinuria: This condition resembles
1. Hereditary/Genetic
Marfan's syndrome. The differences are mentioned
in the table. 2. Chromosomal: Turner's syndrome (45XO),
Down's syndrome, Noonan's syndrome, etc.
7. Klinefelter's syndrome:
3. Constitutional growth delay
a. Lower segment more than the upper segment
4. Delayed puberty
b. Gynecomastia
5. Nutritional: Malnutrition, malabsorption, rickets
c. Small, firm testes, azoospermia
6. Endocrine: Growth hormone deficiency,
d. Chromatin (Barr) body usually present
hypopituitarism, hypothyroidism, excessive
(47XXY). Some may be chromatin negative.
androgens, Cushings syndrome, congenital
e. Mental retardation may be associated. adrenal hyperplasia
f. Associated with mongolism and leukemia. 7. Skeletal: Achondroplasia, spinal deformities,
g. Chronic pulmonary disease, varicose veins skeletal dysplasias
and diabetes are more common 8. Systemicdiseases: Renal tubular acidosis, uremia,

11
PRACTICAL MEDICINE

congenital cyanotic heart disease, cirrhosis of low hairline, square and shield-like chest, cubitus
liver, etc. valgus and mental retardation. Although short,
they grow at the rate of less than 4 cm each year
Differential Diagnosis with normal bone age and dental age but absent
1. Hereditary: In hereditary short stature there is pubertal growth spurt, so that during adolescence,
no endocrine abnormality. The bone age and the the skeletal age is delayed due to the absence of
dental age are normal. Although they are short, sex hormones (streak ovaries).
they grow at a constant rate of 4-5 ems a year and Giving them oxandrolone 0.15 mg/kg/day with
they have normal body proportions for age. This growth hormone from early adolescence till
may be either genetic (if there is a family history of puberty can increase the height. After the age of
short stature) or primordial (if there is no family 15 years cyclical estrogen replacement therapy
history of short stature). The latter may be due to in physiological doses is given for life. Growth
intrauterine growth failure or postnatal growth hormone replacement is recommended before
retardation. These children require no endocrine epiphyseal fusion.
treatment. 4. Hypopituitarism (including Growth Hormone
2. Constitutional growth delayand delayed puberty: deficiency): These children have the skeletal age
This disorder is common among adolescent boys. and the dental age delayed by more than 2 years.
There is no true endocrine deficiency. They grow The growth rate is less than 4 cm/year. The ratio
at a constant rate of about 4 cm a year but their of the upper segment and the lower segment is
bone age and dental age is delayed by about 2 normal. They have genetic defects (prop- I, pit­
years. Often there is a history of delay in growth I gene deficiency). MRI shows hypoplastic or
and pubertal development in the father and other aplastic pitutaries. Growth hormone replacement
male relatives. is necessary.
If puberty does not occur spontaneously by 15 years 5. Hypothyroidism: These children have mental,
of age, it can be induced by testosterone enanthate dental and skeletal retardation since birth. There
250 mg IM once a month for 3 months. would be coarse dry skin and constipation. Their
3. Turner's syndrome (SHOX gene deficiency): body proportion is infantile i.e. upper segment
These children are girls who have agenesis of is more than lower segment. Lifelong thyroxine
their ovaries. The chromosomal pattern is 45XO. replacement is required.
They have a characteristically short webbed neck, 6. Achondroplasia: Achondroplastic dwarfs have
short limbs resulting in short stature. Hence,
Table 2.3 : Differential Diagnosis of Short Stature (Dwarfism)
Constitutional Hereditary Hypopituitarism Hypothyroidism Turner's syndrome

1. Family history + +
2. Birth wt. and height N ,I. N N ,I.
3. Pattern of growth Slow from birth Slow from birth Slow few months Slow from birth Slow from birth
4. Features Immature but Mature Immature Infantile Characteristic
later normal features
5. Bone age Slight delay N Progressive Marked N
retardation retardation
6. Dentition N N Delayed Delayed N
7. Mental status N N N Retarded Retarded/N
8. Puberty Later but normal N Delayed Marked delay Absent
eventually

12
( 2 ) General Examination

Table 2.4 :Vitamins


Vitamin (Daily Sources Deficiency State Therapeutic dose
Requirement)

1. Vitamin A Carrot, Spinach, sweet Night Blindness, Bitot's spots 500 IU/kg/day I.M.
(5000 IU, 80001U potatoes, milk, liver and Xerophthalmia, Keratomalacia, Toxic effects: Painful bone
in pregnancy) fish liver oils Imperfect enamel formation. Exostosis, premature epiphyseal
Follicular hyperkeratosis of fusion. Pruritus, intracranial
skin hypertension, anorexia,
irritability, dry itchy skin, sparse
hair

2. VitaminD Milk butter, yeast, fish, Tetany and rickets in children 5001U/day
(4001U) liver oil, egg yolk, Synthesis Osteomalacia in adults Toxic effect: Anorexia,
in skin when it is irradiated vomiting, diarrhea, lassitude,
thirst, sweating and headache

3. VitaminE Whole rice, wheat germ oil, In man- No symptoms Uses:


(2 00/400/ lettuce, maize, molasses, In animals - habitual abortion, 1. Premature infants
6 001U/day) peas and meat testicular degeneration, etc . 2 . Retrolental fibroplasia
3. G.PD deficiency - to prevent
hemolysis

4. VitaminK Green vegetables, cabbage, Hemorrhagic diathesis 10mg lM


(40mg/day) spinach, tomatoes, egg yolk. Uses:
It is also synthesised in the In newborn, to prevent
intestines. Haemorhagic Disease of New
born

5. Vitamin81 Whole grain, cereals, yeast, Anorexia and nausea, Dry & 100mg orally or IM
(Thiamine) beans, liver, meat, egg yolk wet beriberi, Wernicke's
(1-2mg/day) encephalopathy. Korsakoff's
psychosis

6. Riboflavin Germinating seeds, milk Angular stomatitis, cheilosis 10mg orally


(2 mg/day) eggs, liver or magenta tongue, corneal
vascularisation, scrotal
dermatitis

7. Nicotinic acid Rice, liver, brain, eggs, Erythema, Pigmentation, 500 mg orally.
(15-2 0mg) meat and yeast hyperkeratosis of skin, Toxic effects: itching,
seborrhea around the nose, flushing, amblyopia, liver
raw red tongue, diarrhea, dysfunction and hyperuricemia
dementia and paraplegia.

8. Pantothenic acid Whole grain, milk, eggs, Burning feet syndrome 4-10mg orally
(3-10mg) liver, kidney, meat

9. Pyridoxine/ Yeast, cereals, lettuce, Nasolabial seborrhea, 50-1000mg orally


Vitamin86 spinach, milk, eggs, meat cheilosis, glossitis, peripheral Uses:
and liver neuropathy, convulsions, 1. With INH, cycloserine, oral
(1-2 mg/day)
hypochromic microcytic contraceptives, hydrallazine
anemia, lymphocytopenic and and D-penicillamine
eosinophilia 2. Alcoholism
3. Hyperemesis gravidarum,
Motion sickness, radiation
sickness
4. Sideroblastic anemia
5. Agranulocytosis
6. Infantile convulsions
7 . Homocystinuria, hyperoxaluria
and Hartnup's disease

13
PRACTICAL MEDICINE

Table 2.4 : Vitamins (Contd...)


Vitamin (Daily Source5 Deficiency State Therapeutic do5e
Requirement)

10. Inositol Green citrus fruits, grains, yeast. Not known in man. In animals
(not known) - alopecia, dermatitis and fatty
liver

11. Biotin Liver, eggs, meat. Not known in man


12. Choline Egg yolk, liver, meat Fatty liver and cirrhosis 3-6mgorally
Hemorrhagic renal lesions
13. Folic acid Yeast, fresh green vegetables, Pernicious anemia, Glossitis lSmg orally
(0.05-0.2 mg) cereals, liver, kidney, meat

14. Cyanocobala- Liver, Synthesized in colon Pernicious anemia, Glossitis, 100 mcg orally or IM
min but not useful to the host as Subacute combined degene­
Vitamin 8 12 it is excreted and not ration of spinal cord.
(1 mcg) absorbed

15. Vitamin( Green vegetables, citrus Scurvy 50-100 mg/day


(Ascorbic acid) fruits, strawberries, potatoes Toxic Effects: Uses : Scurvy.
1. Oxalate and urate stones Wound healing, common cold,
2. Iron overload in iron storage Threatened abortion, Alkalosis.
disease Methemoglobinemia
Alkaptonuria, prickly heat
With iron therapy
Hemorrhagic disease of newborn

3 > Nutrition
the lower segment is always less than the upper
segment. Their mental and dental ages are normal
and so are the endocrine functions. A normal person is well nourished as regards proteins,
7. Systemic diseases: Most chronic systemic diseases fats, carbohydrates, vitamins and minerals. Certain
can cause growth failure during childhood. These clinical signs help to diagnose deficiency of one or
illnesses can be recognized by their own specific more of these nutrients.
clinical features and growth failure is a secondary 1. Proteins: Hypoproteinemia causes rough skin
problem. and later edema of feet and brittle hair.
2. Fats: Fat malnutrition leads to cachexia with

ortions
hollowing of cheeks, loss of the shape of hips (due
to loss of fats), flat abdomen and absent fat over
Normally, in adults, the height of the person is equal the subcutaneous tissues of the elbows.
to the length of arm span. The upper segment (from 3. Carbohydrates: Carbohydrate malnutrition
vertex to the pubic symphysis) is equal to the lower is difficult to detect clinically because there is
segment (from pubic symphysis to the heel). gluconeogenesis from fats or proteins.
In infants, the upper segment is greater than the lower 4. Vitamins: These can be fat soluble (Vitamins A,
segment and the height is greater than the arm span. D, E, K) or water soluble (rest) and are discussed
This infantile type of body proportion persists in in the tables.
achondroplasia, cretinism and juvenile myxedema. 5. Minerals: Deficiency of two minerals can be
The reverse of infantile body proportion i.e. arm span diagnosed clinically. Iron deficiency causes
greater than height and lower segment greater than koilonychia and pallor whereas calcium deficiency
upper segment occurs in eunuchoidism, Marfan's causes tetany.
syndrome, homocystinuria, Klinefelter's syndrome
and Frohlich's syndrome.

14
< 2 > General Examination

4 > Decubi�_u_s ____


b. Cyanotic congenital heart diseases,
Eisenmenger's physiology
Decubitus or the posture a patient adopts when lying c. Atrial myxoma
in bed often gives a valuable diagnostic clue. 3. Alimentary
1. Hemiplegia: The patient lies in bed with one side a. Ulcerative colitis
immobile, the affected arm flexed and the affected
leg externally rotated and extended. b. Crohn's disease
c. Cholangiolitic cirrhosis
2. Meningitis and tetanus: The patient has neck
stiffness and opisthotonos. d. Biliary cirrhosis
3. Colic: In renal, biliary or intestinal colic, the e. Hepato-pulmonary syndrome
patient is markedly restless and tossing and 4. Endocrine
turning in bed in agony. a. Myxedema
4. Acute inflammatory abdominal disease: The b. T hyroid acropachy (thyroid nails of
patient lies on his back quietly with legs drawn hyperthyroidism e.g. in Grave's disease)
up.
c. Acromegaly
5. Cardiorespiratory embarrassment: The patient
5. Miscellaneous
is more comfortable in sitting-up position. This
position is also assumed in abdominal distention a. Hereditary
and ascites when intra-abdominal pressure is b. Idiopathic
raised. c. Unilateral: Pancoast tumor, subclavian and
6. Pneumonia and pleurisy: The patient is most innominate artery aneurysm
comfortable lying on the affected side because d. Uni digital: Traumatic or tophi deposit in gout
the movement on the affected side is restricted.
e. Only in the upper limbs in heroin addicts due

5 > Clubbing
to chronic obstructive phlebitis

Grades
Definition I. Softening of nail bed
II. Obliteration of the angle of the nail bed
Clubbing is bulbous enlargement of soft parts of the
terminal phalanges with both transverse and longitu­ Ill. Swelling of the subcutaneous tissues over the base
dinal curving of the nails. The swelling of the terminal of the nail causing the overlying skin to become
phalanges occurs due to interstitial edema and dilation tense, shiny and wet and increasing the curvature
of the arterioles and capillaries. of the nail, resulting in parrot beak or drumstick
appearance (Figs. 2.1 & 2.2).
Causes IV. Swelling of the fingers in all dimensions associated
1. Pulmonary with hypertrophic pulmonary osteoarthropathy
causing pain and swelling of the hand, wrist etc.
a. Bronchogenic carcinoma, mesothelioma
and radiographic evidence of subperiosteal new
b. Lung abscess bone formation (commonly seen in bronchogenic
c. Bronchiectasis carcinoma, paraneoplastic syndromes).
d. Tuberculosis with secondary infection
Schamroth's Sign (Fig. 2.3)
e. Diffuse fibrosing alveolitis
Normally when two fingers are held together with
f. Empyema nails facing each other, a diamond-shaped space is
2. Cardiac seen at the level of proximal nail fold. This is lost in
a. Infective endocarditis case of clubbing

15
PRACTICAL MEDICINE

enters the systemic circulation, it causes dilation


ofarteriovenous anastomosis and hyp ertrophy of
((( the terminal phalanx resulting in clubbing.

\
3. Platelet-derived growth factor causing
vasodilatation.
(a) Pseudoclubbing

___JI(��--=�:
In hyp erparathyroidism or leprosy excessive bone
resorption may result in disappearance of the ter­
minal phalanges with telescoping of soft tissues and
a 'drumstick' appearance of the fingers resembling
clubbing. However, the curvature of the nail is not
(b) present.
: Fig 2.1 (a)& 2 1 (b) (a) Normal nail bed, Profile angle=
180°, (b). Severe clubbing- hypertrophy of soft tissues,
\
I_
__ Pr�file an_gle � � �0 _
°
---� 6 > �ianosis
DEFINITION: Cyanosis is a bluish discoloration ofthe
nails due to increased amount of reduced hemoglobin
(more than 5 mg%) in capillary blood.

Types
I. Central
II. Peripheral
III. Cyanosis due to abnormal pigments
No space
IV. Mixed
Space
Table 2.5 : Differences between Central
and Peripheral Cyanosis
Central Peripheral

1. Mechanism Diminished Diminished


arterial oxygen flow of blood to
saturation the local part
2. Sites On skin & mucous On skin only
membranes
e.g. tongue, lips,
Normal Schamroth's sign
cheeks etc.
Fig 2 3: Left: Normal; Right Schamroth's sign
I • n --- � --- ----- - --�
-
3. Temperature Warm Cold
of the limb
Mechanism
4. Clubbing and Usually Not associated
1. The exact mechanism is not known. It is believed polycythemia associated
that the stimulus for clubbing is hypoxia. Hypoxia
5. Local heat Cyanosis remains Cyanosis
leads to opening of deep arteriovenous fistulas, abolished
which increase the blood supply of the fingers
6. Breathing pure Cyanosis Cyanosis persists
and toes causing it to hypertrophy. oxygen decreases
2. Another hyp othesis is that when reduced ferritin
in venous blood escapes oxidation in the lungs and

16
....
N
'Y

"';:
c;".l

CYANOSIS

;:!
Warm extremities tongue Cold extremities, Only in upper limbs / Cold extremities 5·
and blue tongue ;:,
also cyanosed pink tongue lower limbs ::.
C;:

I�"" I Peripheral
Mixed
(See separate flow chart)

Low BP Normal BP Sudden dyspnea Progressive


frothy dyspnea

Cold Exposure Diarrhea Precordial pain, Local arterial Plethoric face I Acut!LVF I Mitral

I
Thrombophtebitis vomiting perspiration constriction
hemorrhage Stenosis

Hypovolemic Myocardial Raynaud's Polycythemia Differential


Shock Infarction Disease
Cardiogenic
Shock
Upper Limbs Lower Limbs

I
PDA with Transposition of PDA with reversal of
great arteries with reversal of shunt shunt
Preductal Coarctation
of Arteries

'""'
'-l

00

CENTRAL CYANOSIS

Giddiness Effect of oxygen


No Cardio-Respiratory
signs
No improvement Improvement
Blood electrophoresis

I ClubbingPoly­ LoudP 2 Sudden Gradual High attitude


ythemia Sing]e Dyspnea Dyspnea

I
Abnormal Normal
globulin

I
globulin

�-�r
Hb-M Spectroscopy of Dry cough Hemoptysis Clubbing Following
disease Pleuritic Instrumentation
Fallot's Eisenmenger
chest pain
Tetrad Complex
Pul. Atresia Primary or
Secondary Pulmonary Pneumothorax Pulmonary Collapse
Right to Foreign Body
Band at Band at 618 Hypertension Embolism Stricture
Left Shunt
630mU mU

Methemoglobin Sulphemoglobin

No cough Hemoptysis Exacerbation


and remission
R
Interstitial Bronchogenic I CO,PD I r
)>

Fibrosis Carcinoma m
0
R
zm
{ 2 ) General Examination

Mechanism IV. Cyanosis due to abnormal pigments:


Normal hemoglobin has iron in ferrous form. In
In an adult, on an average, there is 15 gm% of hemo­
methemoglobinemia, iron is in the ferric form
globin, 95% of which is saturated with oxygen and
designated as MHb. Several substances like nitrite
only 5% i.e. 0.75 gm% is reduced. Hence, in capillar­
ingestion (well water), sulfonamide or aniline
ies, a mean of the two i.e. only 2-3 gm% is reduced
dyes oxidize Hb to MHb, but this is immediately
hemoglobin and the color of the skin and mucous
reduced back to Hb by methemoglobin reductase
membranes is pink.
I or diaphorase I. If there is deficiency ofdiaphorase
When the amount is reduced hemoglobin exceeds 5 I, MHb circulates in blood, causing cyanosis.
gm% in the capillaries, the blood appears dark, giv­
Colour ofbloodis chocolate brown. The MHb levels
ing the tissues a bluish hue. This is seen earliest in the
warm areas with increased capillary circulation e.g. should be> 1.5 g/dl to cause cyanosis.
palate, tongue, inner sides of the lips and conjunctiva. Sulfhemoglobin (SHb) is an abnormal sulphur
Peripheral cyanosis occurs due to slowing of blood, containing substance, which is not normally
which allows more time for removal of oxygen by the present but is formed by toxic action of drugs
tissues, so that cyanosis is visible on the tip of nose, and chemicals like sulphonamides, phenacetin,
ear lobule, tip of finger, nailbed and cheek. In mixed and acetanilide. SHb forms an irreversible change
cyanosis there is both arterial hyp oxemia and sluggish in the Hb pigment that has no capacity to carry
circulation. oxygen and causes cyanosis. SHb levels should
be >0.5 g/dl to cause cyanosis.
Causes
Differential Cyanosis
I. Central:
A. Cardiac I. Only oflower limbs - Patent ductus arteriosus
(PDA) with reversal of shunt.
1. Congenital, cyanotic heart disease: Fallot's
tetrad, Eisenmenger's complex etc. II. Only of upper limbs - PDA with reversal of
shunt in a transposition of great vessels.
2. Congestive cardiac failure.
B. Pulmonary III. Cyanosis of left upper limb and both lower
limbs - PDA with reversal of shunt and pre­
1. Chronic obstructive lung disease.
ductal coarctation of aorta.
2. Collapse and fibrosis oflung.
3. Marked pulmonary destruction due to Conditions where Cyanosis does not
any cause. Occur
4. Pulmonary AV fistula. 1. In severe anemia where hemoglobin is less than
C. Abdominal hepato-pulmonary syndrome. 5 gm%, even if all the hemoglobin is reduced in
the capillaries, it will be less than the critical level
D. High altitude due to low partial pressure of
of 5 gm% and cyanosis does not occur.
oxygen.
2. In carbon monoxide poisoning, carboxy­
II. Peripheral:
hemoglobin prevents reduction ofoxyhemoglobin
A. Cold (local vasoconstriction) and the former has a cherry red color. Hence there
B. Increased viscosity of blood is no cyanosis.
C. Shock

7 > Jaundice
D. Reynaud's phenomenon
III. Mixed
A. Acute left ventricular failure Definition
B. Mitral stenosis (leftatrial failure and peripheral Jaundice is a symptom complex which is characterized
vasoconstriction).

19
PRACTICAL MEDICINE

by yellow coloration of tissues and body fluids due Distribution of Jaundice


to an increase i.n bile pigments. It may arise due to:
Since bilirubin binds with circulating pro­
1. Increased bile pigment load to the liver. teins, it is more evident if proteins are increased
2. Affection of bilirubin diffusion into the liver cells. e.g. exudates. Again, bilirubin has more affin­
3. Defective conjugation. ity for nervous tissue e.g. basal ganglia and elastic
4. Defective excretion. tissues e.g. skin, sclera and blood vessels.

Other Causes of Yellow Coloration of


Tissues
Yellow coloration of tissues can occur due to caroten­
emia and mepacrine therapy.
Normal Values
Serum bilirubin: Total: 1 mg%, Direct: 0.25 mg%.
Urinary bilirubin is present if direct bilirubin is greater
than 0.4 mg% in serum. Etiology
Urine urobilinogen: 100-200 mg/day. I. Hemolytic (Pre-hepatic)
Fecal stercobilinogen: 300 mg/day A. Intra-Corpuscular Defects:
1. Hereditary spherocytosis.

Table 2.6 : Differential Diagnosis of Jaundice


Hepatoce/Jular Obstructive Hemolytic

I. HISTORY:
1. Abdominal pain Absent Present Present in crisis
2. Pruritus Transient Marked Absent
3. Past history a) Contact with a) Pain (Stones) a) Of crisis
jaundice patient b) Weight loss (Neoplasm) b) Drugs, blood
b) Drugs c) Surgery (Stricture) transfusion etc.
II. EXAMINATION:
1. Tender liver May be present Absent Absent
2. Spleen May be present Absent Present
3. Gall bladder Not palpable Palpable if due to neoplasm Not palpable
4. Pallor Absent Present Present
II. INVESTIGATIONS:
1. Urine:
Bilirubin Present Present Absent
Urobilinogen Present Absent Present
2. Stools:
Sterocobilinogen Present Absent Present
3. Peripheral smear Leucopenia in Normal Reticulocytosis
infective hepatitis Spherocytosis
4. L.F.T.
a) Bilirubin ++ ++ +
b)Alkaline phosphate Raised Markedly raised Normal
c)SGO T Markedly raised Raised Normal
s. Barium meal and cholangiography Normal May reveal pancreatic growth Normal
6. RBC survival Normal Normal Decreased

20
< 2 > General Examination
RBC
0

�'>8oRES
1. Breakdown
phase

1
Free bilirubin

2. Conjugation
phase

"'--
Urobilinogen

4. Renal
excretion
phase

Stercobilinogen

Fig. 2.4: Bilirub1n Metabolism

Bilirubin Metabolism

s
1. Breakdown phase: Hemoglobin released
by breakdown of aged cells is broken
down into globin and heme in the
spleen. The heme is further broken into �
iron and bilirubin. Bilirubin attaches to
serum albumin and is transported to
the liver where it is taken up. Bilirubin
(unconjugated) bound to albumin cannot
be excreted by kidneys. 1l] .s
-t-� ...�
.!
Conjugation phase: In the liver, bilirubin t .a �
� bl) ...0
:=
.t
2. -
u.l
C.
O .D 1:1:l <
is separated from albumin and conjugated :=
to glucuronide by glucuronyl transferase. ...
C
"'... � ... ...
e' .gp:�
0 (U
.D "' � (U

u uZ
The conjugated bilirubin is water-soluble
"'
;,!: "'>
and can be excreted by kidneys. z U)
0

3. Alimentary phase: The conjugated j§


bilirubin is excreted through the
bile canaliculi and reaches the intestines .!u
=
"'O
where it is converted to stercobilinogen "'O 2:lC "6h "'
0 ...
·a'-�
�;E "'O 0
and urobilinogen by the intestinal
1
>
"'
bacteria. About 70% of this is absorbed in 0 c:: � Cl
ul .D
� Po.
the colon and brought back to the liver and

.. "'...."'
re-excreted (enterohepatic circulation).
ii "'
Unabsorbed sterco-bilinogen gives � ;a
brown color to the feces. ·a... ·s..
0
:9
(U

4. Excret i o n p h a s e : Ci r c u l a t i n g
2:l u.l
..s c:s :a
urobilinogen is carried to the kidneys
for excretion in the urine as urobilinogen.

21
PRACTICAL MEDICINE

2. Hemoglobinopathies:Sicklecellanemia, C. Cirrhosis
homozygous beta thalassemia, sickle 1. Portal
thalassemia, HbE thalassemia
2. Biliary
3. Enzyme deficiency (E6PD, pyruvate
3. Hemochromatosis
kinase).
IV. Obstructive (Surgical Jaundice- Post­
4. Paroxysmal nocturnal hemoglobinuria
hepatic):
(PNH)
A. Extra-Hepatic:
B. Extra-Corpuscular Defects:
1. Inflammatory: Stone, stricture, parasites,
1. Infections: Malaria, Clostridium welchii
acute cholecystitis
2. Drugs: L. Methyl dopa, quinine,
2. Neoplastic: Carcinoma of the head of
phenacetin, sulfonamides
the pancreas; neoplasm of bile ducts,
3. Physical agents: Burns, Irradiation gall bladder and ampulla ofVater
4. Poisons: SnakeVenom, Favism 3. Congenital: Biliary atresia
5. Immunological: Mismatched blood B. Intra-Hepatic:
t r a n s fu s i o n , p a r o x y s m a l c o l d
1. Cholestatic phase of infective
hemoglobinuria, lymphoma, CLL, SLE.
hepatitis
6. Miscellaneous: Uremia, cirrhosis ofliver
2. Drugs: Steroids, chlorpromazine,
II. Congenital Hyperbilirubinemia PAS, sulfonamides, chlorpropamide
A. Unconjugated: tolbutamide, methyl testosterone,
1. Disturbance of bilirubin transport: erythromycin.
Gilbert's syndrome. 3. Pregnancy with cholestasis.
2. Disturbance of bilirubin conjugation:
Crigler Najjar syndrome.
B. Conjugated: Disturbance in excretion of
8 > Pallor
bilirubin: Dubin Johnson syndrome and Pallor is paleness ofskin and mucous membrane either
Rotor's syndrome. as a result of diminished circulating red blood cells or
III. Hepatocellular (Medical Jaundice-Hepatic) diminished blood supply.
A. Infections Causes
1. Viral hepatitis
I. Anemia
2. Weil's disease (Leptospirosis)
A. Hemorrhagic
3. Septicemia
B. Hemolytic
4. Malaria, Typhoid
C. Dyshemopoietic
B. Toxic
1. Deficiency ofiron, folic acid orVitamin
1. Anesthetic agents: Halothane, B 12
chloroform
2. Aplastic anemia
2. Anticoagulants: Phenindione
3. Systemic and infiltrative diseases
3. Anti-tuberculous drugs: Rifampicin,
4. Chronic infection
P.A.S., I.N.H., Thiacetazone
5. Pregnancy
4. Metals: Arsenic, mercury, gold, bismuth
6. Malignancies
5. Chemicals: D.D.T.
6. X-ray irradiations

22
{ 2 } General Examination
II. Vasoconstriction The supratrochlear lymph nodes are palpated on the
A. Shock : Hyp ovolemic / cardiogenic medial aspect of the arm between the groove ofbiceps
and brachialis muscle, an inch above the arm fold.
B. Exposure to cold
The inguinal nodes are examined in the supine position
C. Fright
with the thigh extended. Both the medial and lateral
D. Syncope and postural hypotension groups of lymph nodes are examined.
E. Arterial Occlusion Scalene nodes are present behind the sternomastoid
III. Cutaneous muscle and may be palpable. In suspected malignancy,
A. Thick skin and nails biopsy it taken from that area, even if the nodes are
B. Edema (edema causing diseases) not palpable.

C. Myxedema Inspection: Most of the superficial lymph nodes are


visible when enlarged. The site of lymphadenopathy
Sites where anemia is detected often gives the clue to its cause. Tuberculosis often af­
1. Lower palpebral conjunctiva fects the upper deep cervical nodes, secondary syphilis
2. Tongue affects supratrochlear nodes, carcinoma of stomach
3. Soft palate affects the left supraclavicular nodes whereas filariasis
affects the inguinal nodes.
4. Palm and nails
The skin overlying the lymph nodes may show redness
5. Other mucosa! areas like vaginal or rectal mucosa
indicating underlying inflammation. Ulceration or
sinus may be present in tuberculosis.
Palpation: Raised temperature and tenderness is noted.
If present, suggests acute inflammation. The surface
is smooth normally but matted in tuberculosis and
irregular in malignancy and inflammation.
The consistency of the nodes is noted. Normally it
is firm. It is rubbery in Hodgkin's disease, firm and
shotty in syphilis, matted in tuberculosis and hard in
malignancy. The mobility of the nodes is noted. Nor­
mally they are mobile and free from skin. In certain
Lymphadenopathy is inflammatory or non-inflam­ inflammatory conditions and malignancy they may
matory enlargement of lymph nodes. be fixed and non-mobile.
Examination
The lymph nodes of the neck should be examined by
standing behind the patient with the patient's neck
slightly flexed. The nodes must be examined from
above downward - submental, submandibular, tonsil­
lar, cervical, posterior auricular & occipital groups.
In the left supra-clavicular fossa, a lymph node may
be palpable (Virchow's nod�) which occurs due to
metastasis from stomach or testicular malignancy.
The axillary glands should be examined by inserting
the fingers in the axilla with the patient's arm slightly
abducted. The arm is then abducted and the apical,
anterior, posterior, medial and lateral groups oflymph
nodes are examined.

23
PRACTICAL MEDICINE

Causes and pitting on pressure at the periphery will be


evident. It is often difficult to differentiate from
I. Inflammatory tuberculous Iymphadenitis.
A. Acute Lymphadenitis
B. Chronic Lymphadenitis: Tuberculous Lymphadenitis
1. Septic 1. Commonly affects the deep cervical, mesenteric
2. Tuberculosis and axillary glands.
3. Syphilis 2. The lymph nodes may be discrete (when it
resembles chronic septic lymphadenitis) or may
4. Filariasis be matted due to periadenitis. If caseation has
5. Lymphogranuloma inguinale occurred, cold abscess results which may burst
6. HIV with PGL or AIDS forming tuberculous ulcer or sinus which takes
II. Neoplastic a long time to heal.
A. Primary: Lymphosarcoma 3. Fever with chills weight loss, anorexia and
respiratory complaints may be present.
B. Secondary: Carcinoma, sarcoma, malignant
melanoma Syphilitic Lymphadenitis
III. Hematological: 1. Painless, firm, discrete and shotty glands which
A. Hodgkin's disease do not suppurate.
B. Non-Hodgkin's lymphoma 2. In secondary syphilis, generalized lymph­
C. Chronic lymphatic leukemia adenopathy occurs involv ing especially
IV. Immunological: Serum sickness, drug reaction, epitrochlear and occipital glands.
SLE and rheumatoid arthritis 3. Other evidence of syphilis with positive tests for
syphilis like WR, VDRL, TPI, and FTA ABS.
Causes of Generalised Lymphaenopathy
Filarial Lymphadenitis
1. Tuberculosis
2. Infectious Mononucleosis 1. Pain, tenderness and swelling of the inguinal
lymph nodes, spermatic cord and scrotum.
3. Secondary Syphillis
2. Lymphangiectasia (dilation oflymph vessels) of
4. H.LV. the inguinal region and spermatic cord.
5. Hodgkins Lymphoma 3. Eosinophilia and microfilaria can be demonstrated
6. Lymphatic Leukemia in the blood.
7. Sarcoidosis, Brucellosis, Toxoplasmosis 4. Lymph node biopsy may reveal adult worm.
Differential Diagnosis Lymphogranuloma lnguinale
Acute Lymphadenitis 1. Suppurative lymphadenitis with ulceration, sinus
formation and extensive scarring of the inguinal
1. Enlarged, tender and fixed lymph nodes. lymph nodes.
2. Overlying skin may become red, hot and brawny. 2. Frei's test is confirmatory.
3. Primary infective focus may be found.
Lymphosarcoma
Chronic Septic Lymphadenitis 1. Commonly affects the cervical glands which are
1. Enlarged, slightly tender lymph nodes which may enlarged, firm and fixed.
or may not be matted. 2. The overlying skin is stretched and shiny with
2. If abscess has occurred, fluctuation in the centre dilated blue veins under it.

24
< 2 > General Examination
3. Highly malignant tumor grows rapidly and Infectious Mononucleosis
invades the surrounding tissues.
1. Acute onset offever, chills, sore throat, headache,
Secondary Carcinoma malaise and tiredness occurs
1. The nodes are enlarged, irregular and fixed to all 2. The lymph nodes are enlarged, discrete and
structures including the skin. slightly tender affecting especially the cervical
and submandibular nodes.
2. It has stony hard consistency.
3. Non-tender splenomegaly may occur.
3. Primary growth may be detected.
4. Petechial rash may occur at the junction of soft
4. Patient may be cachectic and wasted.
and hard palate on the fourth day and may persist
Hodgkin's Disease for 3-4 days.
Affects young adolescent males. 5. Peripheral smear shows leucocytosis (absolute
1.
lymphocyte count more than 1500/cmm) with
2. Cervical glands are affected early but later all atypical lymphocytosis.
lymph nodes are involved.
6. Paul-Bunnel test may be positive in 1:32 dilution
3. Lymph nodes are elastic and rubbery, discrete or more usually in the first l O days.
and movable with little tendency towards matting,
softening or suppuration. HIV Associated Lymphadenopathy
4. Pressure symptoms: Edema, venous engorge­ l. Commonly called PGL or persistent generalised
ment and cyanosis of head and neck may occur lymphadenopathy.
due to pressure on the superior vena cava and the
2. Usually seen in stage of intermediate
bronchus by the mediastinal glands. Root pains
immune depletion following HIV infection
and paraplegia may develop due to pressure on
(Refer Pg. 113).
the spinal cord.
Hepatosplenomegaly and anemia occur.
> Edema
5.
6. Pel Ebstein's type of fever (recurrent bouts of 10
remittent fever) may occur.
Edema is the collection offluid in the interstitial spaces
7. Weight loss more than 10% of body weight and or serous cavities. It becomes evident only when 5-6
night sweats. liters of fluid has accumulated in the water depots.
8. Peripheral smear will show lymphocytosis and Pitting on pressure occurs when the circumference
eosinophilia. of the limb is increased by l 0%.
9. Lymph node biopsy will show Reed Sternberg's
Mechanism
cell.
One or more of the following factors may be respon­
Non-Hodgkin's Lymphoma sible.
Similar to Hodgkin's lymphoma in clinical presenta­ 1. Increased capillary permeability when it is
tion except: damaged e.g. acute inflammation.
1. Enlargement of nodes in Waldeyer's ring and 2. Increased capillary pressure e.g. cardiac failure.
supratrochlear glands 3. Decreased osmotic pressure of the blood e.g.
2. Symptoms are less common hypoproteinemia.
3. Can be a manifestation of HIV infection 4. Damaged lymphatic drainage e.g. filariasis.
4. Diagnosis confirmed by histologicalexamination
Site
of the bone marrow.
Venous edema commonly occurs in the lower limbs

25
PRACTICAL MEDICINE

which are most dependent. However, if the patient


is recumbent,. edema may be present only over
the sacral region which is, then, most dependent.
Lymphatic edema may occur in either limbs or over
scrotum depending upon the site of involvement.
Causes
Bilateral:
A. Cardiac: CCF, LVF, pericarditis
B. Renal: Acute nephritis, nephrotic syndrome
C. Hepatic: Cirrhosis of liver, portal hypertension
D. Venous: Inferior vena cava obstruction
E. Endocrine: Myxedema
F. Allergic: Angioneurotic edema
G. Nutritional: Anemia, hypoproteinemia,
beriberi.
H. Toxic: Epidemic dropsy

Differential Diagnosis
1. Cardiac
A. Congestive Cardiac Failure: The edema is
found on the most dependent parts ofthe body
as gravity plays an important part. Hence, in an
ambulatory patient edema is in the feet, ankles
and legs whereas in the recumbent patient it
is mainly over the sacrum, lumbar region and
Unilateral: genitalia. It is most marked in the evening.
A. Lymphatic: B. Left ventricular failure: Accumulation offluid
1. Filariasis in the lung occurs much earlier than edema of
the feet, resulting in dyspnea, cough and basal
2. Pressure by new growth, metastasis
rates.
3. Radiation
C. Pericardial effusion: Since there is obstruction
B. Traumatic: Bruises, sprains, fractures to the flow of blood into the right atrium,
C. Infections: Cellulitis, boils, carbuncle edema of feet may occur, but no edema of
D. Metabolic: Gout lungs occurs because the heart is able to pump
the little blood it receives into the lungs and
E. Venous: Venous thrombosis, varicose veins.
general circulation. It is associated with raised
F. Hereditary: Milroy's disease JVP, hepatomegaly and ascites.

26
( 2 ) Ge11eral Examination

2. Kidney pitting, associated with puffy face, weight gain,


A. Acute nephritis: Edema is generalized and weakness, alopecia, hoarse voice, rough dry skin,
not restricted to the dependent parts of constipation, anemia and menstrual disturbances.
the body. It is more noticeable in the early 6. Allergic (Angioneurotic edema): This often
morning. The fluid accumulates initially in resembles myxedema with swelling over the face
the loose connective tissues, hence it is most and limbs. There is usually intense itching and
marked around the eyelids and face. The bronchospasm.
cause of edema is damage to the endothelial 7. Nutritional: This is characterized by dependent
lining of the capillaries, disturbance of fluid edema with puffiness of face, pallor and cachexia.
and sodium excretion and later also due to 8. Filariasis: In filariasis, edema occurs due to
hyp oproteinemia. destruction of the lymphatic filter action of the
B. Nephrotic sydrome: Swelling is generalized lymph glands with consequent blocking and
and massivedue to hypoproteinemia following dilation of the lymph vessels. Subsequently there
massive albuminuria. is transudation of lymph, rich in proteins, into
3. Hepatic (Portal hypertension): Here ascites the tissues. Later connective tissues proliferate
occurs before edema of feet. This occurs due to leading to elephantiasis. This is characterized
hypoproteinemia and compression of the hepatic by unilateral non-pitting edemawith rough skin.
branches of the portal vein. Ascites leads to There may be history offever with rigors especially
pressure on the venous circulation in the lower at night and initially pitting edema . Blood smear
limbs leading to edema of the legs. may show microfilaria.
4. Venous (Inferior vena cava obstruction): This is 9. Gout: This commonly affects the big toe with
characterized by bilateral nondependent painless marked pain, edema and deformity of the part
pitting edema. Collateral dilated veins are usually involved. Tophi may be present. There may be
present in the flanks with flow of blood from history of renal colic or renal stones.
below upwards. 10. Venous Thrombosis: This is characterized by
5. Endocrine (Myxedema): Here edema is non- unilateral painful pitting edema.
UNILATERAL EDEMA

Painless Paillful

Ons.et
I Involves only Part of the limb Involves the
From birth big toe with affected and whole limb
Late onset
Tophi painful
Milroy's ! Filjiasis !
Disease
I Glut I
Cellulitis
Linear and
streaks
I
Present Absent
Filariasis Venous
Thrombosis

27

BILATERAL EDEMA

Onset

With loss of With puffy face With Ascites Pitting Edema feet Generalised
weight, without any
Cachexia, Polyarthritis cause
Starvation
Hypertension Sudden onset Constipation Dialated veins JVP raised
Hematuria I Wheezing Itch- Rough skin over chest and Ascites JVP raised Idiopathic
Proteinuria ing Hoarse voice Hepat<>megaly Chest signs
abdomen

Malnutrition, Nephritic j Angio- ! Myxe�ema I Pericardia]


PEM, syndrome I II neurotic Effusion
Kwarshiorkor
-
Edema H/0
Diuretic
Hypoproteinemia, Absent intake
Massive edema feet Splenomegaly Present only left Present
Hyperlipidemia,
limb
Proteinuria,
Lipiduria
Inferior Vena Cava I I Portal !L tF! Cardiac Nutritional r:.reti ,
I uced
Obstruction Hypertension Failure

Nephrotic DRUGS CAUSING EDEMA


syndrome
Calcium Channel blockers
Estrogens �
Steroids
Carbenoxolone

0
R
z
l
< 2 ) General Examination

11 > Skin and its occur in typhoid, syphilis and purpura. If they
are not generalized, they are called roseolar.
---- A��endag_e_s���- 2. Papules: (Raised tiny nodule < 5 mm): This
Examination of skin often gives important clues to may occur in measles, chickenpox, smallpox
local or systemic diseases. The following features and following drugs like sulfonamides.
should be noted: 3. Pustules: These are papules containing pus.
I. Color: It may be pale, flushed, cyanosed, yellow, 4. Nodules: (Large papules as solitary projection
etc. from the skin : 5 mm - 5 cm). This may occur
II. Pigmentation: Pigmentation may occur in several in erythema nodosum, leprosy, tuberculosis,
diseases. Some common medical conditions secondary syphilis.
associated with pigmentation are: 5. Vesicles: (small blisters < 5 mm). This may
1. Endocrine: Addison's disease, Cushing's occur in herpes, chickenpox and smallpox.
disease, thyrotoxicosis. 6. Bullae: Fluid-filled lesion > 5 mm.
2. Deficiency: Pellagra, Kwashiorkor, 7. Wheal: (Elevated patches on the skin with
megaloblastic anemia. centre paler than the periphery) Allergy.
3. Infections: Kala azar, chronic malaria, V. Neurocutaneous Stigmata (Phakomatoses)
secondary syphilis, tuberculosis, leprosy, HIV,
1. Cafe-Au-Lait spots:
etc.
Dark brown patches resembling coffee in
4. Metabolic: Hemochromatosis.
milk. They are considered significant if they
5. Skin disease: Neurofibromatosis, lichen are more than 5 in number or single one> 15
planus, acanthosis nigricans, etc. mm. They are seen in:
6. Miscellaneous:Malignancy, pernicious anemia, a. Neurofibromatosis (regular outline
exposure to sunrays or radiations. without deep indentations)
III. Hypopigmentation: Hypopigmented patches b. Albright's syndrome (irregular outline
may occur in leprosy, leukoderma, albinism, with deep indentations)
fungal infections of skin, etc.
c. Tuberous sclerosis
IV. Eruptions: Various types oferuptions may occur
Schwartz criteria for significant cafe-au-lait
as follows:
spots
1. Macules: (Not raised above the skin). This may
a. > 5 in number, more than 2 cm

Fig 2 11 Hyperp1gmented knuckles due to n1egaloblast1c


anemia
-----�--- ---- - - -- ·-

29
PRACTICAL MEDICINE

b. Two> 5 cm 2. Mois t skin: This occurs when there is


c. One in axilla profuse perspiration as in shock, following
myocardial infarction, crisis of pneumonia
d. Axillary freckle
and thyrotoxicosis.
2. Tuberous sclerosis: (EPILOIA)
3. Thick skin: This occurs in Myxedema,
fu;tllepsy acromegaly and scleroderma.
LowlQ 4. Thin skin: This occurs in old people and
Adenoma Sebaceum following wasting diseases.
3. Sturge Weber Syndrome: 5. Pinched skin: suggests dehydration.
Hemangioma on face and cerebrum VIII. Hair: Changes in hair that occurs in some of the
diseases are as follows:
l. Falling of hair: Following infectious fevers
e.g. typhoid.
2. Patchy hair loss: Alopecia areata, syphilis.
3. Loss of outer third of the eyebrows: Leprosy,
Myxedema.
4. Absence of axillary, pubic and facial hair:
Hypopituitarism, hypogonadism.
5. Excessive hair growth in women: Cushing's
syndrome, adrenocortical syndrome.
IX. Nails: The nails should be examined for the
VI. Hem orrhage: Hemorrhage under the skin may
following:
be classified as follows:
l. Pallor
l . Purpura: Hemorrhage into the skin
2. Koilonychia: Spoon-shaped deformity of the
a. Palpable: Vasculitis syndromes due to
nail which is present in iron deficiency anemia.
inflammation of the vessel wall.
3. Onychia: Deformity of the nail e.g. following
b. Non-Palpable:
fungal or tuberculous infection.
i. Petechiae <3 mm
4. Disc oloration:This occurs in Raynaud's disease
ii. Ecchymosis > 3 mm and silver and mercury poisoning.
2. Hematoma: Hemorrhage large enough to 5. Clubbing and cyanosis (Refer Pgs. 15, 16)
produce elevation of skin.
Causes of hemorrhage under the skin:
l. Deficiency: Vitamin deficiency, scurvy.
2. Infection: Meningococcal meningitis, SBE,
HIV
3. Hematological: Thrombocytopenia, acute
leukemia, chronic lymphatic leukemia, chronic
myeloid leukemia (in terminal phase) platelet
dysfunction and aplastic anemia.
VII. Types of Skin
l. Dry skin: This is seen in myxedema and
dehydration.

I
t 30
( 2 > General Examination

6. Hemorrhages: Splinter hemorrhages may be 2. Postural: Carrying weights on the back


present under the nail beds in SBE and bleeding 3. Disease of bone and joints: Tuberculosis
disorders. (Pott's spine), rheumatoid arthritis, rickets,
7. Trophic changes: Ribbing, brittlenessand often osteoarthritis, osteitis deformans, fracture of
falling of nails may occur in syringomyelia, the vertebral body, new growth of the spine.
leprosy and tabes dorsalis. 4. Neurological: Muscular dystrophy, hereditary
spastic paraplegia, Friedreich's ataxia ,
syringomyelia, poliomyelitis, cerebral palsy,
12 Vertebral Column neurofibroma, etc.
The vertebral column in a normal upright position Ill. Lordosis
has two antero-posterior curves - one with a concavity
forwards in the upper dorsal region and the other with Lordosis isan abnormal anteroposterior curvature
a slight convexity forwards in the dorsolumbar region. of the spine with forward convexity.
Normally, there is no lateral curvature. The vertebral Causes:
column should be examined for any abnormality, l. Physiological: Pregnancy
angular deformity, swelling or tenderness.
2. Secondary to hip disease and congenital
Normally the vertebral column has both anterior as dislocation of the hip
well as lateral mobility. This can be tested by asking
3. Muscular dystrophy
the patient to bend forwards, backwards and sideways.
Limitation of movements and pain, if any, should be 4. Large abdominal tumors
looked for.

I. Scoliosis
Scoliosis is an abnormal lateral curvature of the
spine.
Causes:
l. Congenital
2. Postural: Carrying heavy weight in one arm.
3. Compensatory: Reduced length of one lower
limb.
4. Reflex: To relieve pain as in sciatica or renal Normal Scoliosis Kyphosis Gibbus Lordosis
colic
Fig 215:VertebralColumn
5. Neurological: Poliomyelitis, syringomyelia,
muscular dystrophy, hereditary ataxia.
IV. Pes Cavus
6. Rickets
Pes cavus is the increased anteroposterior
7. Functional
curvature of the arch of the foot.
II. Kyphosis Causes:
Kyphosis is an abnormal anteroposterior l. Idiopathic
curvature of the spine with forward concavity 2. Spinocerebellar atrophy: Friedreich's ataxia,
and dorsal prominence. peroneal muscular atrophy
Causes: 3. Spinal cord disease: Poliomyelitis, spina bifida
L Congenital: Wedge shaped vertebra. 4. Cerebral palsy

31
PRACTICAL MEDICINE

13 > Thickened Nerves


C. Movements (active and passive):
1. Pain on movement
Causes: 2. Restriction of movement
I. Leprosy 3. Excessive mobility
2. Neurofibromatosis 4. Protective muscular spasms
3. Diabetes 5. Grafting on movement
4. Amyloidosis D. Measurements:
5. Charcot Marie Tooth syndrome 1. Length of the limb
6. Sarcoidosis 2. Circumference of the limb
7. Refsum's disease 3. Relations of various bony points
8. Rusy Levy syndrome
Ill. General And Systemic Examination
9. Dejerine Sotta's syndrome
IO. Idiopathic hypertrophic neuropathy l. Evidence of gonorrhea, syphilis and
1 I. CIDP (Chronic Inflammatory Demyelinating tuberculosis
Polyneuropathy). 2. CNS: A.R. pupils, Rhomberg's sign and absent
deep reflexes (syphilis); dissociate anesthesia,

14 > Joints
flaccid weakness in the upper limb and spastic
paraplegia (syringomyelia).

Causes of Arthritis
I. History
1. Onset Acute Arthritis
2. Pain and swelling in the joint 1. Traumatic
3. History of trauma, tuberculosis, typhoid, 2. Infection: Gonorrhea, septic, typhoid, bacillary
exposure to venereal disease, pneumonia, dysentery, rheumatic, Reiter's syndrome. etc.
bacillary dysentery, bleeding tendencies, renal
3. Gout
colic.
4. Scurvy
4. Family history of hemophilia, tuberculosis
gout, etc. 5. Hemophilia
6. Acute attacks in chronic arthritis
II. Examination of Joints
Chronic Arthritis
A. Inspection:
1. Joints affected I. Infection: Tuberculosis, syphilis, rheumatic
2. Position of the joint and fixed deformity 2. Collagen disease: Rheumatoid, SLE., Polyarteritis
3. Swelling nodosa
4. Signs of inflammation over the joint 3. Degenerative: Ankylosing spondylitis
5. Muscular wasting just above the joint 4. Neuropathic: Tabes dorsalis, syringomyelia
B. Palpation: 5. Miscellaneous: Hemophilia, gout.
L Local temperature Differential Diagnosis
2. Tenderness
3. Swelling-fluctuant or non-fluctuant Septic Arthritis
4. Bony components and its relation to the 1. Acute onset with symptoms of septicemia
joint

32
( 2 ) General Examination

2. A single large joint or multiple small joints are 2. Arthralgia and hydrarthrosis are seen in
involved secondary syphilis
3. Joints are painful, especially on movement 3. Gummatous arthritis occurs in the tertiary stage
Spontaneous dislocation and fibrous or bony
4. Rheumatic Arthritis
ankylosis may occur.
1. It is common between 5-25 years.
Tuberculous Arthritis
2. There may be antecedent Stre ptococcus
1. There is insidious onset. It commonly affects the hemolyticus infection
upper Jimbs in adults and lower Jimbs in children. 3. T he onset may be rapid with relapses and
2. Tuberculous focus may be present in the body remissions
3. Night starts due to involvement of the articular 4. Multiple joints are affected with fleeting arthritis
cartilage may occur 5. Affected joints may be painful, tender and swollen
4. Muscular deformity and wasting may be present 6. Other evidences of rheumatic fever: Carditis,
5. Rise of local temperature with a spongy feel of the chorea, rheumatic nodules and erythema
thickened synovial membrane may be present marginatum may be present
6. Restriction of movements is common 7. Elevated ESR, positive ASO titer and C reactive
7. Cold abscess and sinus may occur protein may be present
8. X-ray: Generalized decalcification, obliteration Rheumatoid Arthritis
of joint space with erosion of the articular ends.
Pathological dislocation and recalcification may l. It commonly affects women between 24-40
be present. years age
2, Characteristically it is bilaterally symmetrical,
Gonococcal Arthritis affecting the small joints of the hand or foot and
1. It occurs 3 weeks after the primary infection may spread to large joints
2. Onset is sudden, with fever 3. Periodic painful swelling ofthe joints with stiffness
and deformity ( e.g. ulnar deviation of the hand,
3. It may be monoarticular (knee or elbow) or
flexion deformity etc.) may occur
polyarticular and may be manifested by acute
arthralgia or acute arthritis (redness, heat and 4. Muscle spasm and muscle wasting may be present
edema) 5. Restriction of movement is common
4. Gonococci may be demonstrated in urethral 6. X-ray: Decalcification and diminished joint space
discharge. may be seen
Stilt's disease is juvenile rheumatoid arthritis with sple­
Reiter's Syndrome
nomegaly and lymphadenopathy.
This is characterized by multiple acute arthritis, non·
gonococcal urethritis and often conjunctivitis. Osteoarthritis

Typhoid Arthritis l. It is common in men over 40 years


2. Asymmetrical affection of one or more joints is
It occurs in the fourth week of typhoid fever when the present
patient first gets on his feet. There may be spontaneous
3. Morning stiffness especially after rest and at the
dislocation of the hip joint.
onset of movements may be present. It is relieved
Syphilitic Arthritis by movements since the increased synovial
secretion caused by movements lubricates the
l. Characteristically there is painless, symmetrical
dr y joint and relieves the pain.
arthritis with free movements

33
l;,t,)

POLYARTICULAR ARTHRITIS

' I
Acute onset Insidious onset

H/o Injury Fever Fleet ing Large synovial Painful Young female Painful joint Young male,Lumbar Any age,
Malaise joint pains in joints affected infection &Swellings spine and sacro joint pain,
Sore throat young person with pain but Hormonal I H/o fever iliac joints Radiologal
no synovial involved, HLA changes
Traumatic
changes Fever, lymph
I I I thickening or adenopathy, handaffected
Hemato­
B27 posit ive
Endocrine Malignancy
Rheumatic 1
Morming
logical
effusion
I I systemic
stiffness,
Viral arthritis
i nvolvement

I I I Reactive Rh,umato;d Seronegative


f sy novial
infection I arthritis S ,11 ro;n;• o
(nephritis)
Spondyloarthritis

SLE Arthritis Metabolic

Repeated History o f Patient of Valvular or


sore throat exposure with leprosy on congen ital heart

Al and
hard chance dapsone, disease, fever,
12 weeks prior multiple embolic Distal inter Urethritis, con­ Following Rheumatoid
disease Gastrointesti-
to arthritis erythematous episodes uveitis phalangeal junctivitis, diarrhea
nal infection
nodules joint affected, Keratoderm ia,
like Yersinia,
Skin lesions .,'"T'h,g;,
Post- Secondary
I
Shigella
I endocardlitis
Infectiv,
Streptococcal 11 syphilis

Juvenile

Psoriatic Reiter's Postcolitis Post colitis
arthropathy Syndrome Arthropathy rheumatoid arthropathy
arthritis
R
)>
r
Ankylosing
:I
spondylitis
m
0
R
zm
( 2 ) General Examination
4. Pain restricts movements. Grafting may be felt
on passive movements
5. Heberden's nodes may be present.
6. X-ray: Diminished joint space with osteophytes
may be seen

Gout
1. It occurs usually in obese men between 25·40
years
-� �� .�
- "'
·-
2. There is asymmetrical affection of the big toe.
0
"'il .. Later other joints may be affected. Relapses and
e;,.. .c
t: remissions are common.
� e
0
"'
o:I
CII 3. There is sudden onset of acute agonizing pain
0 ::i::
usually at night
4. Initially the tissues around the joint are red,
swollen and edematous. Later, ligaments and bone
ends are infiltrated by the chalky deposits which
form tophi. If the skin over the tophi gives way,
i
·o·� C chalky discharge results.
""
V
0
� 5. Movements are painful. Muscles wasting may
8 V
... Q. occur later
"8 I>()
V C
Cl ::J 6. Serum uric acid is elevated
� :S
V
>
V
u..
Hemophilic Joints
l. It is common in young boys with positive family
history. It is a sex-linked recessive disorder
2. There is sudden painful bilateral hemorrhagic
effusion into the knee joints
3. Clotting time is increased, activated partial
thromboplastin time (APTT) is prolonged
and antihemophilic globulin (AHG) levels or
Christmas factor levels in blood are low
4. Ultimately chronic disabling arthropathy results

Neuropathic Joints
1. Osteoarthritis in the denervated joints (Tabes
dorsalis, syringomyelia, peripheral neuropathy)
2. There is little pain but marked destruction of the
bone.

Scurvy
1. It is common in malnourished children
2. There is painful swelling of the knee joint
3. Hemorrhages and petechial hemorrhages in

----
35
PRACTICAL MEDICINE

skin and at hair roots may occur which requires pneumonia, typhoid, urinary tract infection,
examination with magnifying glass. infective endocarditis, brucellosis, typhus, etc.

Ankylosing Spondylitis
1. It is common in boys between 15 25 years
in ::r,�
Temperature
' �:;:
ttenl

--:=:,¥.·. ,:=-�----
\··,. ..":°/� -
105 / .
104
••• �:.-::,... , Con. lrnuous
2. There is insidious, progressive involvement of
103 fever
spinal joints especially sacroiliac joint 102 -·· •• .... : .':. ·� ....
101 : ', ; •• .' ••
3. Movements of the joint are restricted due to 100 ,: ', / \ .: ':.. Intermittent
pain and stiffness. Later, there is kyphosis and ...... •• • •.... fever

progressive ankylosis 7)).-.,)'

4. Muscles spasms and atrophy may be present. Fig 2 1 6 Types offevers

2. Remittent fever: The temperature remains


�>Temperature __ above normal throughout the day and fluctuates
more than 1•c in 24 hours e.g. typhoid, infective
The body temperature refers to the temperature of endocarditis, etc. This type of fever is most
the viscera and tissues of the body. It is kept within common in practice.
the normal level by maintaining a balance between
3. Intermittent fever: The temperature is present
the heat gain and heat loss, which is regulated by the
only for some hours in a day and remits to normal
hypothalamus.
for the remaining hours. When the spike occurs
The body temperature is best recorded with a mercury daily, it is quotidian, when every alternate day, it
thermometer, which should be kept in position for is tertian and when every third day, it is quartan.
about a minute. Usually temperature is recorded in Intermittent fever is seen in malaria, kala-azar,
the axilla. However, if there is a lot of perspiration, pyemia, septicemia etc.
oral temperature should be taken. In cholera, rectal
4. Hectic or septic: The temperature variation
temperature is recorded which may be high, whereas
between peak and nadir is very large and exceeds
the skin temperature may be subnormal.
s·c e.g. septicemia.
The normal body temperature varies from 36° C
5. Pel Ebstein type: There is a regular alternation
-37.5°C. There is normally a diurnal variation of 1•c,
of recurrent bouts of fever and afebrile periods.
the lowest temperature being between 2-4 am and
The temperature may take 3 days to rise, remains
highest in the afternoon.
high for 3 days and remits in 3 days, followed by
Fever or pyrexia is an increase of more than 1 °C or any apyrexia for 9 days seen in Hodgkin's lymphoma.
rise above the maximal normal temperature. The follow­
6. Low grade fever: Temperature is present daily
ing terms are used when recording the body temperature:
especially in the evening for several days but does
Temp in °C Temp in °F
not exceed 37.8° Cat any time. Usually it does not
1. Hypothermia 35
°
95°
2. Subnormal 35.0-36.7° 95-97°
indicate disease, but it is commonly present with
3. Normal 36.7-37.2° 98-99° tuberculosis.
4. Mild fever 37.2-37.8" 99-1000
5. Moderate fever 37.8-39.46 100-103•
Causes of Fever
6. High fever 39.4-40.Se
103-105· l. Infections: Bacterial, viral, rickettsial, fungal
7. Hyperpyrexia >40.5° > 10s•
parasitic, etc.
Types of Fever 2. Neoplasms: Fever may be present with any
neoplasm but commonly with hypernephroma,
1. Continuous fever: The temperature remains lymphoproliferative malignancies, carcinoma of
above normal throughout the day and does not pancreas, lung and bone and hepatoma.
fluctuate more than 1°C in 24 hours e.g. lobar

36
( 2 } General Examination

3. Vascular: Acutemyocardial infarction, puhnonary 4. Fever with membrane in the throat: Occurs in:
embolism, pontine hemorrhage, etc. a. Diphtheria
4. Traumatic: Crush injury. b. Infectious mononucleosis
5. Immunological: C. Agranulocytosis
a. Collagen disease, SLE, rheumatoid arthritis. d. Moniliasis
b. Drug fever e. Vincent's angina.
c. Serum sickness 5. Fever with delirium: This is common in:
6. Endocrine: Thyrotoxicosis, Addison's disease. a. Encephalitis
7. Metabolic: Gout, porphyria, acidosis, dehydration b. Typhoid state
8. Hematological: Acute hemolytic crisis c. Meningitis
9. Physical agents: Heat stroke, radiation sickness. e. Pneumonia (especially in alcoholics and elderly
10. Mi scellaneous: Factitious fever, habitual people with dementia)
hyperpyrexia, cyclic neutropenia f. Hepatic encephalopathy
Special Types of Fever 6. PUO (Pyrexia of Unknown Origin)
a. Temperature > 101°F (38.3 °C) on several
Fever with rigors: This occurs in:
occasions.
a. Malaria
b. Duration >3 weeks
b. Kala azar
c. Duration > l week in hospital with failure to
c. Filariasis reach diagnosis.
d. Urinary tract infection, pyelonephritis Classification
e. Cholangitis a. Classical PUO (lymphoma, collagen
f. Septicemia vascular disease, abcess, TB, viral infection,
g. Infective endocarditis endocarditis)
h. Abscesses, any site b. Nosocomial PUO: hospitalized, no fever
i. Lubar pneumonia on admission (thrombophlebitis, catheter
infections, deep vein thrombosis, drug fever,
2. Fever with herpes labialis: Elevated body transfusion reaction)
temperature may activate the herpes simplex
virus and cause small vesicles around the angle c. Neutropenic PUO: Absolute neurophil count
of the mouth (herpes labialis). It occurs with: <500 (fungal infection, perianal infection)
a. Pneumonia d. PUO in HIV infection (TB, Pneumocystis
j iroveci, toxoplasma, cryptococcus, CMV, Non
b. Malaria Hodgkins Lymphoma).
c. Meningitis
Hyperpyrexia
d. Severe streptococcal infection
3. Fever with rash: This is seen in: Hyperpyrexia is said to occur when body temperature
is more than 10s·F.
a. Chicken pox
b. Small pox Causes
c. Measles 1. Tetanus
d. Rubella 2. Malaria
e. Typhus 3. Septicemia
g. Allergy 4. Heat Stroke

37

FEVER

Shrot duration Long duration

r1-,
Without With
I
Abdominal
1
Headache,
I
Valvular lesion
I
Cough,
Abd. pain, Past
I
I
Hepato- Cough,
specific specific pain, Rose spots, Vomiting, Neck Petechiae, Clubbing, Loss of history Amebic, splenomegaly, Haemoptysis,
symptoms symptoms Bradycardia stiffness Palpable spleen Weight anorexia dysentery Lymphadenopathy Breathlessness

I Influenza
I
I I 1TypLid I I Meningitis I I Endocarditis I Pulmonary 11 Amebic liver
I Tuberculosis Lymphoma
I
Brucellosis
I Abscess I I Leukemia Other
Occupational
hazards
Other signs of Throat pain, Cough, Chest Rigors Rashes
Viremia, Progressive
weight loss, High
Difficulty in
swallowing
pain, Rusty
sputum I
H/o Drug Ingestion

I
Risk Behaviour

Tonsillitis
-
Pneumonia I
HIV Infection Pharyngitis Burning Micturition Present Absent
Diphtheria
Infectious Drug Allergy Measles
Mononucleosis , Chickenpox
1
Absent Present

Urinary Tract Infection DRUGS CAUSING FEVER


Alternate day Lymphedema, Abscess Aminosalicylic acid
fever Eosinophilia Antipsychotics

I MaLia ! Filariasis Septicemia


Amphotericin
Penicillin
Antihistamines nz
Novobiocin
( 2 > General Examination
5. Encephalitis
6. Pontine hemorrhage
7. Neuroleptic malignant syndrome

Benefits of Fever
In some human diseases, fever is beneficial, e.g. wide·
spread cancer, neurosyphilis, chronic arthritis, etc.
Fever was often induced in these diseases by injection
of milk protein or BCG vaccine.
It has been suggested that fever is associated with release
of endogenous pyrogens, which activate the T cells and
thus enhance the host defense mechanism.

Harmful Effects
l. Hypercatabolism-nitrogen wastage and weight
loss.
2. Fluid and electrolyte imbalance· due to sweating.
3. Convulsions and brain damage
4. Circulatory overload, arrhythmias, etc.

Hypothermia
Hypothermia is decreased body temperature.

Causes
l. Endocrine: Hypothyroidism or myxedema,
hypopit uitarism (Simmonds cachexia),
hypoglycemia
2. Toxic: Alcoholic intoxication, barbiturate
poisoning, ketoacidosis
3. Exposure to cold
4. Autonomic dysfunction or dysautonomias

16 > Pulse
Definition : Pulse is a wave which is felt by the finger,
produced by cardiac systole travelling in the peripheral
direction in the arterial tree at a rate faster than the
column of blood.
tidal or percussion wave which is felt.by the palpating
A normal pulse wave is transmitted peripherally tak­
finger. On the following downstroke there is a notch
ing 30 msec to reach the carotids, 60 msec to reach (dicrotic notch) followed by a wave (dicrotic wave)
the brachial artery, 80 msec to reach the radial artery both of which are not normally palpable.
and 75 msec to reach the femoral artery.
Pulse is assessed by:
The normal pulse has a small anacrotic wave on the
upstroke, which is not felt. This is followed by a big l. Rate (No. of beats/min)

-
39
PRACTICAL MEDICINE

4. Equality
5. Peripheral pulses (e.g. femoral, posterior tibial,
dorsalis pedis)
6. Radio-radial delay (pre-ductal coarctation
of aorta), radio-femoral delay (post ductal
coarctation of aorta) (Refer Pg. 255)
7. Apex pulse deficit (atrial fibrillation)
The normal pulse appears at regular intervals and
has a rate between 60-100 per min. There may be a
mild variation in the rate between the two phases of
respiration which is called sinus arrhythmia.

Fig 2 23 Normal pulsewavt: a Anacrot1cv,ave, t tidal


v,ave;cJ d1crotic v,ave; n:d1crot1c notch;S:Systole;
D: Diastole
- - -- -- - - -- ----- -- --
I. Anacrotic Pulse: is a slow rising, twice beating
pulse where both the waves are felt during systole.
The waves that are felt are the anacrotic wave and
the tidal wave. It is best felt in the carotids in aortic
stenosis.

a. Tachycardia (Refer Pg. 422)


b. Bradycardia (Refer Pg. 422)
2. Rhythm
' F,g 2 24:Tv,,1(1:bl:i1!111ql\1){JCfOl1Cp-ulWfslow ri'>1n9)
a. Regular - -- cc. ---

b. Regularly irregular (e.g. second degree II. Pulsus Bisferiens is a rapid rising, twice beating
heart block 3:2, 4:3, Wenkeback; Ventricular pulse where both the waves are felt during systole.
Bigemini or Trigemini). Here the percussion wave is felt first followed by
a small wave. It is seen in:
c. Irregularly irregular (e.g. atrial fibrillation,
ventricular or atrial ectopics) A. Idiopathic hypertrophic subaortic stenosis: Here
initially there is no obstruction to the outflow
3. Force, volume, tension

40
(2 > General Examination

s D s D

F,g 2 27 Pulsus parvuset tardus

V. Pulsus Altern ans is characterized by a strong and


weak beat occurring alternately, probably due to
F,g. 2.25 · Pulsus B1sfer1ens (rap1d-rrs1ng)
alternate rather than regular contraction of the
and about 80%ofthe stroke volume is ejected in muscle fibers of the left ventricle.
the early part of systole. The obstruction occurs
Causes
in mid systole when aortic valve approximates
the hypertrophied septum. Hence, there is a A. Left ventricular failure
dip, as suddenly the flow ceases, followed by B. Toxic myocarditis
a secondary rise as the L. V. overcomes the C. Paroxysmal tachycardias
obstruction.
D. For several beats following a premature beat
B. Severe A.I. with mild A.S.: The volume flow is
initially increased due to severe A.I. Mild A.S.
causes an extra high velocity jet to be shot out
resulting in the second wave.
III. Dicrotic Pulse is a twice-beating pulse where the
first percussion wave is felt during systole and the F,g 2 28 Pulsusalternans
second dicrotic wave is felt during diastole. It is
seen when the peripheral resistance and diastolic VI. Pulsus Paradoxus: Normally systolic blood
pressures are low as in: pressure falls by 3-10 mm. during inspiration.
A. Fevers like typhoid fever This is because though there is increased venous
B. Congestive cardiac failure return to the right side of the heart there is relative
pooling of the blood in the pulmonaryvasculature
C. Cardiac tamponade as a result of lung expansion and more negative
D. Following open heart surgery intrathoracic pressure during inspiration. This
decreases the venous return to the left atrium
s D s D and ventricle and subsequently causes a fall in
left ventricular output decreasing the arterial
pressure. When the systolic blood pressure falls
more than 1 O mm. Hg. during inspiration the pulse
is erroneously called pulsus paradoxus although
it merely is an exaggeration and not a reversal of
the normal.
The paradox of this phenomenon is that in
F,g 2 26 D1crot1c pulse extreme cases the peripheral pulse can disappear
on inspiration while, paradoxically, heart sounds
IV. Pulsus Parvus Et Tardus is a slow-rising pulse
remain audible during the "missed beats".
with a late systolic peak (Pulsus Tardus) and
which is also low in volume and amplitude (Pulsus A reverse pulsus paradoxus may occur in
Parvus). It is characteristically seen in severe patients receiving continuous airway pressure
Aortic Stenosis. It is best felt in the carotids. on a mechanical ventilator.

41
PRACTICAL MEDICINE
Causes Causes
A. Superior vena cava obstruction. A. Physiological
B. Lung conditions. l. Fever
I. Asthma 2. Chronic alcoholism
2. Emphysema 3. Pregnancy
3. Airway obstruction B. High output states or syndromes
C. Cardiac 1. Anemia
l. Pericardial effusion 2. Beriberi
2. Constrictive pericarditis 3. Cor pulmonale
3. Severe congestive cardiac failure 4. Cirrhosis ofliver
NB: If the thoracic cage is immobile as in 5. Paget's disease
ankylosing spondylitis, pulsus paradoxus does 6. Arteriovenous fistula
not occur.
7. Thyrotoxicosis
VII. Pulsus Bigeminus ( Coupling) is coupling ofthe
C. Cardiac lesions
pulse waves in pairs, followed by a pause.
1. Aortic regurgitation
Causes 2. Rupture of sinus of Valsalva into the
A. Alternate premature beats. heart chambers
B. A.V. block, every third sinus impulse being 3. Patent ductus arteriosus
blocked 4. Aortopulmonary window
C. Sinoatrial block with ventricular escape. 5. Bradycardia
6. Systolic hypertension

--
Fig 2 29 Puls us b1gem1nus
- - --- --------------
VIII. Thready Pulse: The pulse rate is rapid and the
pulse wave is small and disappears quickly. This
is seen in shock especially cardiogenic.
IX. Waterhammer Pulse is a large bounding pulse
associated with increased stroke volume of the
left ventricle and decrease in the peripheral
resistance, leading to a wide pulse pressure. The
pulse strikes the palpating finger with a rapid,
forceful jerk and quickly disappears. It is best
felt in the radial artery with the patient's arm
elevated. It is caused by the artery suddenly
emptying because some of the blood flows back
from the aorta into the ventricle.

F,�1 2 3'.) W3to:-rha,11n1t!f Pulse


----- � -- � ---------·- .

42
( 2 ) General Examination

Fig. 2.32 Measurement ofJugularVenous Pressure

I
I
I
I

'
I
I
I
I I I y
- a wave

-
svc rium contractirig:
TV open

-"
"'
cwave
Ventricle contracting
TV closed; bulging into RA
Usually palpation of Carotid Pulse gives better infor­
mation about the character of pulse than peripheral
arteries like the Radial artery. However Pulses Alter
nans, Bisferiens and water hammer pulse are better
x wave (descent)
felt at the peripheral arteries. Atrium relaxing then
Apex Pulse Deficit fill ng; TV closed

It is thedifference between the heart rate and pulse rate,


counted simultaneously, by two people, for 1 minute.
When only one person is examining, the radial artery vwave
is palpated simultaneously while ausculating the apex. RA full, tense;
The heart beats which are not transmitted to the radial TV closed
pulse are counted as the Apex Pulse Deficit.
i. Apex Pulse Deficit > 6 - Atrial Fibrillation
ii. Apex Pulse Deficit < 6 - Ventricular. Premature
y wave (descent)
Beats.
Rapid ventricular filling;
RA emptying; TV open

17 > Jugular Venous Pulse


(JVP)
Normal: 3-5 cm
Procedure: The patient is given a backrest to keep him

43
PRACTICAL MEDICINE

at 45°. In this position, normally, the internal jugular a Systole


vein is just seen above the clavicles. The upper level of
the vein is noted and a ruler is kept at that level, parallel
to the ground. Another rule is put perpendicular to the
first ruler up to the angle of Louis. The distance from
the angle of Louis to the first ruler gives the jugular
pressure. In the supine position the jugular pressure
may falsely appear elevated whilst in the upright posi­
tion it is falsely lowered.
Significance: The jugular veins are in direct continuity I F,g.2 35 :JVP in tricusp,d stenos1s giant 'a' wave
with the superior vena cava and the right atrium. Hence
it reflects pressure changes in the right atrium. 2. Ventricular tachycardia.
NORMAL JVP: The normal JVP consists of three 3. Ectopic beats.
positive pulse waves (a, c and v) and two negative THE 'C' WAVE is produced by two events:
pulse waves (x and y). 1 Systole1
!Systole I Diastole
THE 'K. WAVE is produced by retrograde transmis­ I
I
I
I a I
I
I
I
sion of the pressure pulse produced by right atrial I I I I
contraction. In normal subjects the 'a' wave is often I I I I
the largest positive wave visible, coinciding with the r I I I
I I I I
fourth heart sound. a I
v' r I

Abnormalities of 'a' waves:

: Fig 2.36 .JVP in complete heart block-cannon wave


I

A Impact ofthe carotid artery adjacent to the jugular


vein.
B. Retrograde transmission ofa positive wave in the
F1g.2 34 · JVP ,n atrial flbrillat,on Absent'a' wave
right atrium produced by the right ventricular
A. a' wave is absent in atrial fibrillation systole and the bulging of the tricuspid valve into
B. a' wave is diminished in the right atrium.
1. Tachycardia It normally begins at the end of the first heart sound
and reaches its peak shortly after the first heart sound.
2. Prolonged PR interval
a'
The 'c' wave is not often seen clinically.
C. Large or giant waves are present in
THE 'X' WAVE: 'x' descent is produced by:
1. Tricuspid stenosis
A. The downward displacement of the tricuspid
2. Tricuspid atresia valve during ventricular systole and resultant fall
3. Right atrial myxoma in right atrial pressure.
4. Pulmonary stenosis B. Continued atrial relaxation.
Abnormalities of 'x' wave
5. Pulmonary hypertension
a'
D. Cannon waves occur in --
A. The 'x' descent is obliterated or may be replaced
1. Complete heart block when the right atrium
by a positive wave ('s' wave) in tricuspid
and right ventricle contract simultaneously
regurgitation. This 's' wave may fuse with the 'c'
with a closed tricuspid valve.
and 'v' waves to produce a giant 'V' wave (Fig.
2.24).
44
{ 2 > General Examination

Abnormalities of 'y' descent:


Diastole
A. Rapid for HRCP 'y' descent occurs in
I. Constrictive pericarditis (Friedreich's sign).
2. Severe heart failure.
3. Tricuspid regurgitation (Early & Deep).
B. A short 'y' descent occurs in tricuspid stenosis on
rt. atrial myxoma.
Elevated venous pressure occurs in
Fig 2.37 JVP 1n tricusp1d regurg1tat1on-severe
obliteration of 'X descent and prominent 'V'wave I. Right ventricular failure
- -----------. -··- ---··--
2. Cardiac tamponade
Diastole 3. Tricuspid stenosis
4. Superior vena cava obstruction
5. Hyperkinetic circulatory state
6. Increased blood volume
7. Pulmonary diseases like asthma, emphysema

Fig 2 38 JVP in constr1ct1ve per1card1t1s-usually a


µrominent Y' descent (top) Sometimes 'X" descent may
be more prominent than 'Y' descent (bottom) 1
--·- -- __________________ ___J

B. The 'x' wave may sometimes be prominent in


constrictive pericarditis (Fig. 2.25). Cardiac
tamponade restrictive chodeography
IBE'V' WAVE occurs because ofright atrial filling with
the tricuspid valve closed during ventricular systole. Differences between JVP and
Abnormalities of'v' wave: Giant 'v' waves, as discussed Carotid Pulse
earlier, appear in tricuspid regurgitation. JVP Carotid Pulse

THE 'Y' WAVE: The 'y' descent is produced by open­ 1. Appearance Better seen Better felt
ing of the tricuspid valve and subsequent rapid inflow than felt than seen
of blood from the right atrium to the right ventricle 2. Number of waves Multiple Single
leading to a sudden fall ofpressure in the right atrium 3. Pressure below the Obliterates the No change
which is reflected in the jugular veins. It corresponds angle of mandible wave
with the third heart sound. 4. Changes with Present Absent
The ascending limb of the 'y' wave is due to continu­ respiration and
ous diastolic inflow ofblood into the great veins, right change of position
atrium and ventricle, which are all in free communica­
tion during diastole.

45
inn--
PRACTICAL MEDICINE

Kussmaul's sign: Normally inspiration lowers the Phase I: The first appearance of faint clear tapping
JV pressure giving an inspiratory collapse, because sounds (Thuds) which gradually increase in
intrathoracic pressure falls and there is increased intensity.
blood flow into the thorax. In contrast, when the Phase II: The softening of the sounds which may
intrapericardial pressure is raised as in constrictive become swishing or blowing.
pericarditis there is a paradoxical increase in JV pres­
Phase III: The return of sharper softer sounds,
sure on inspiration. This is Kussmaul's sign.
which become crisper, but never fully regain the
Hepatojugular Reflux intensity of phase I sounds. Neither phase II nor
phase III has any known clinical significance.
Normally, when pressure is applied over the abdomen
• Phase IV: Distinct abrupt muffling of sounds,
(right hypochondrium) for 30 seconds, initially there is
a rise in JV pressure (due to increased venous return), which become soft and blowing.
followed by a fall (due to the capacity of normal myo­ • Phase V: The point at which all sounds disappear
cardium to accommodate the extra venous return). completely.
However, in early cardiac failure, even before jugular Phase I is taken as systolic pressure and phase V as
pressure is elevated, there is a sustained elevated pres­ diastolic pressure.
sure in the jugular veins (for more than a minute) on
pressure over the abdomen because the failing heart
cannot compensate for the extra venous return. This Systolic
is positive hepatojugular reflux. Phase I Thud
120 mmHg
There is no rise in jugular venous pressure on apply­ 110mmHg
ing pressure over abdomen in:
Phase II Blowing
l. Budd Chiari syndrome
100mmHg
2. IVC Obstruction
Phase III Softer sounds
Decreased venous pressure in seen in:
90mmHg
1. Shock
2. Dehydration Phase IV Muffling
Diastolic

18 > Blood Pressure


80mmHg
Phase V Disappearance

Systolic BP is controlled by the stroke volume of the Fig 2 40:Korotkoffsound�


heart and the stiffness of the arterial vessels. Diastolic '----

BP is controlled by the peripheral resistance. Apparatus


BP varies from moment to moment with respiration,
1. Mercury sphygmomanometer: The pressure
emotion, exercise, meals, alcohol, tobacco, bladder
changes are reflected by a rise of mercury. It is
distension, temperature and pain. It is also influenced
an accurate method of taking blood pressure.
by circadian rhythm, age and race. BP may be modi­
However, the instrument is bulky and heavy.
fied by obesity or arrhythmia.
2. Aneroidmeter: The pressurechanges are reflected
Shortly after Scopine Riva-Rocci had invented the
by a change in the needle which is connected to
sphygmomanometer, the Russian surgeon Korotkoff
the spring. Though the instrument is small and
suggested that by placing a stethoscope over the
non-bulky, it has to be frequently reset to ensure
brachia! artery at the antecubital fossa distal to the
accuracy.
Riva-Rocci cuff, sounds could be heard. The origin
of these sounds is still not clear. Vibrator y and flow 3. Electronic BP meter: The pressure changes are
phenomenon are probably responsible. The phases are: measured electronically.

46

....
( 2 } General Examination

Technique a large bladder ( 18 x 24 ems) for adults should be


wrapped around the thigh of the prone patient
1. Clothing should be removed from the arm. If it and the Korotkoff sounds auscultated in the
cannot be removed, it is better to leave it as it is, popliteal fossa in the usual way. Diastolic BP
rather than fold the clothing into tight constricting in the legs is equal to that in the arms provided
bands. the bladder is adequate in size. Systolic BP
2. The cuffshould be encircled around the arm. Ifthe in lower limbs is 20 mm Hg more than upper limbs.
bladder does not encircle the arm completely, the 6. For children, pediatric size cuff should be
centre of the bladder should be over the brachial used.
artery. The rubber tubes from the bladder are
usually placed inferiorly at the site ofthe brachia! Guidelines for Measurement of BP
artery, but it is better to place it superiorly or
1. Explain the procedure to the patient to allay
posteriorly so that the antecubital fossa can be
anxiety.
easily auscultated.
2. Avoid exertion, meals or smoking for 30
The normal cuff is 25 cm in length and 12 cm in minutes before BP is measured. No exogenous
width. adrenergic stimulants (e.g. phenylephrine in
3. The bell gives better sound reproduction but a nasal decongestants) should be used. The patient
diaphragm is easier to secure with the finger of must be allowed to rest for 5 minutes before BP
one's hand and covers a large area. is measured.
4. The bladder is inflated quickly to a pressure 20 3. The room should be warm and quiet.
mm Hg above the systolic pressure, recognized by 4. High BP may be erroneous!y recorded in an obese
disappearance of the radial pulse. The bladder is person because the inflatable rubber bladder may
then deflated 2 mm Hg per second. The Korotkoff be too short for the obese arm (Recommended
phase I (appearance) and phase V (disappearance) dimensions are 12 x 35 ems). When the bladder
are recorded to nearest 2 mm. In children, phase IV does not completely encircle the arm, the centre
may be preferable. If Korotkoff sounds are weak, of the bladder must be placed directly over the
the patient is asked to raise the arm and open and brachia! artery.
close thefist 5-10 times before inflating the bladder.
5. The arm must be supported to the heart level.
1he pressure, patient position, the arm and the
In the supine position the arm is usually at the
cuffsize should be recorded.
heart level. In sitting and standing positions the

---- -----------------,
5. To measure BP in the legs a thigh cuffcontaining arm must be horizontal with fourth intercostal
space at the sternum. In normal people there is
Mercury no significant difference in BP between supine,

..r--
sphy�momanomctcr
sitting and standing positions provided the
arm is supported at the heart level. Some anti­
Mcasuring sc:alc
1 hypertensive agents cause postural hypotension
Jntlatablc ;;mprcssmg
bladder enclosed w11hm
and when this is expected, BP must be measured
inextensible cuff \
in both lying and standing positions.
6. Ifthe arm is unsupported, the patient will perform
isometric exercise, which may elevate the diastolic
BP by l 0%. This is especially so in hypertensive
patients on beta-adrenergic blocking agents. To
avoid this the arm must be supported.
lnflallon oolb
sphygmomanomc1cr 7. The BP may be higher in right arm by 2-10 mm
Hg. Most pressures in practice are measured on
Fig. 2 41 Blood Pressure Measurement the right arm. However if the BP is higher by 10

47
----
PRACTICAL MEDICINE

19 > HJ�ertension
mm Hg in one arm further measurements should
be made in the arm with the higher BP.
8. The cuff should be snugly fitted to the arm. A cuff Hypertension {HT) is the silent killer of mankind.
which is too tight may give a false lower blood Most sufferers (85%) are asymptomatic and hence
pressure and a loose cuff may give a false higher early diagnosis is a problem. The dividing line between
BP. normal and abnormal BP is arbitrary because BP is
9. Repeated inflation of the cuff may cause venous dependant upon many factors like age, race, sex, etc.
congestion of the limb and elevate both systolic
Definitions and Classification
and diastolic BP. To avoid this the cuff should
be inflated as rapidly as possible and deflated The definition ofhyp ertension is not universal because
completely between successive readings. At least normal BP varies. The Sixth Joint National Committee
15 seconds should be allowed between successive Criteria (JNC VII) classifies hypertension for adults
measurements. aged 18 years and older into the following stages:
I 0. Auscultatory Gap: Is the interval ofblood pressure Table 2.7 : JNC VII Criteria for
when the Korotkoff sounds disappear and then Classification of Blood Pressure
re-appear at a lower pressure during auscultatory Category Systolic Diastolic
method of measury B.P. This leads to errors of mmHg mmHg
underestimation of systolic BP or overestimation Normal <120 AND <80
of diastolic B.P. This can be avoided by doing the
Pre-Hypertension 120-139 OR 80-89
palpatory method first, followed by auscultatory
method. Hypertension
Stagel 140-159 OR 90-99
Unequal BP in two arms
Stage2 �160 OR �100
I. In normal individuals, BP may vary upto 10 mm
I. Target BP is< 140mmHg systolicand<90mmHg.
Hg in the two arms.
2. Supravalvular aortic stenosis (right sided higher For diabetics OR chronic renal failure BP should
BP) be:
3. Preductal coarctation ofaorta {right sided higher < 130 mmHg systolic; < 80 mmHg diastolic
BP) For diabetics WITH chronic renal failure BP
4. Unilateral occlusive disease of the arteries should be:
- Atherosclerosis, embolism, aortoarteritis, < 125 mmHg systolic;< 75 mmHg diastolic
thoracic outlet syndrome, etc. (BP will be low on 2. Hypertensive emergencies ( malignan t
the affected side) hypertension) are characterized b y severe
elevations in BP (> 180/120 mmHg) with
Conditions Diagnosed by Measuring BP
evidence of impending or progressive target
I. Hypertension organ dysfunction. They require immediate BP
2. Hypotension reduction. (e.g.pappiledema, retinal exudates,
retinal hemorrhages, nephropathy, hypertensive
3. Pulsus paradoxus
encephalopathy, intracerebral hemorrhage, acute
4. Pulsus alternans Ml, acute left ventricular failure with pulmonary
5. Coarctation ofaorta (Hypertension in upper limb, edema, unstable angina pectoris, dissecting aortic
hyp otension in lower limb) aneurysm, eclampsia).
6. Aortic incompetence (Hill's sign) 3. Hypertensive urgencies ( a c c e l e r a t e d
7. A u t o n o mic d y s fu n c t i o n - postural hypertension) are associated with severe
hyp otension. elevations in BP without progressive target
organ dysfunction (e.g. upper levels of stage II

48
< 2 > General Examination
hypertension associated with severe headache, 1. CVS: Increased myocardial work leads to
shortness of breath, epistaxis). Retinal damage concentric hyp ertrophy of left ventricle, angina
may be present but without pappiledema. pectoris and accelerated coronary arter y
4. Isolated systolic hypertension is systolic BP;;;: 140 disease. There is systolic as well as diastolic
mmHg and diastolic BP <90 mmHg. It is seen dysfunction.
predominantly in elderly due to arteriosclerosis. It 2. Kidneys: Progressive arteriosclerosis involves
may fluctuate from time to time, high in morning, both the efferent and afferent renal arterioles
lower at night. and capillaries of glomerular tuft. This leads
s. Pulse pressure = SBP • DBP (Normal 30-60 to compromise in renal function, shrinkage of
mmHg). kidney, proteinuria.
6. Mean BP= 2/3 DBP + 1/3 SBP. 3. CNS:Hyp ertension may cause micro-aneurysms
(Charcot-Bouchard aneurysms) which may
Labile hypertension: The patient is hypertensive at
rupture and cause cerebral hemorrhage.
one time and normotensive at another time.
Accelerated atherosclerosis may cause cerebral
White Coat Hypertension: The patient's BP is high thrombosis, embolism and infarction. Cerebral
when measured by a professional but is normal when arteriolar spasm may cause hypertensive
measured in casual circumstances (at home). It is encephalopathy.
diagnosed by 24-hour ambulatory BP monitoring.
Sites of hypertensive bleed are: cerebellum,
Causes thalamus, basal ganglia (putamen), pons.
1. Essential Hypertension 4. Fundus
Keith Wagner Classification
2. Renal
a. Acute nephritis Grade I: Mild generalized ar teriolar
attenuation.
b. Interstitial nephritis and pyelonephritis
Grade II: Deflection of veins at AV crossing
c. Polycystic kidneys (AV nicking) + marked generalized arteriolar
d. Renal artery stenosis attenuation.
e. Diabetic nephropathy Grade III: Grade II + copper wire + cotton
3. Endocrine: Pheochromocytoma, Cushing's woolspots + flame-shaped hemorrhages + hard
syndrome, thyrotoxicosis, myxedema exudate.
4. Neurological: Raised intracranial tension, lead Grade IV: Grade III + silver wire + papilledema.
encephalopathy, etc.
Symptoms
5. Pregnancy induced HT
The clinical features may be due to the elevated BP
6. Cardiovascular HT: Co-arctation ofaorta, aortic
regurgitation, arteriosclerosis itself, target organ involvement or due to underlying
disease, as in secondary hyp ertension.
7. Drugs: Glucocorticoids, OCPs, sibutramine,
cocaine, etc. Symptoms due to hypertension
8. Miscellaneous: Polycythemia, polyarteritis 1. Headache: This occurs usually in the morning
n o d o s a, o b s t r u c t i v e s l e e p a p n e a, hours. It is throbbing and usually frontal.
hyp ercalcemia
2. Dizziness: The patient feels unsteady
Effects of Hypertension 3. Epistaxis: This occurs due to increased pressure
The common organs damaged by long-standing causing rupture ofthe capillaries ofthe nose. The
bleeding would reduce the circulatingvolume, and
hypertension are heart, kidneys, blood vessels, retina
and central nervous system. lower the BP (Natures way oflowering the BP and
prevention of hemorrhage in the vital organs).

49
PRACTICAL MEDICINE

Symptoms due to Affection of Target 2. Puffy face, rough skin, obesity· Myxedema
Organs 3. Tremors, tachycardia, exophthalmos, thyroid
1. CVS: dermopathy and goitre- Hyperthyroidism
a. Dyspnea on exertion (incipient LVF) 4. Prognathism, dubbed hand, coarse features •
Acromegaly
b. Anginal chest pain (IHD)
5. Pigmentation - Neurofibromatosis
c. Palpitations
2. Kidneys: Hematuria, nocturia, polyuria 6. Radio femoral delay and collateral vessels over
the chest wall · Coarctation of aorta
3. CNS:
7. Weaker left radial - Preductal coarctation
a. Transient ischemic attacks (TIA or stroke)
with focal neurological deficit 8. Waterhammer pulse - Aortic incompetence
b. Hypertensive encephalopathy (headache,
vomiting, convulsions, unconsciousness, focal
neurological deficit)
c. Dizziness, tinnitus and syncope
4. Retina: Blurred vision or sudden blindness
Symptoms due to Underlying Diseases
1. Edema and puffy face - Acute nephritis
2. Weight gain, hirsutism and stria - Cushing's
syndrome
3. Weight loss, tremors, palpitations and sweating
- Hyperthyroidism/pheochromocytoma
4. Weakness - Primary hyp eraldosteronism
5. Joint pains, bronchospasm &peripheral vascular
disease symptoms - Polyarteritis nodosa
Signs
General Examination
1. Moon face, buffalo hump and truncal obesity -
Cushing's syndrome

Cardiovascular System
1. Cardiomegaly
2. Third and fourth heart sound gallop
3. Loud second heart sound
4. Early diastolic murmur - due to Al

so
( 2 ) General Examination

Respiratory System Treatment of Hypertension


1. Basal crepitations • LVF I. Non-pharmacological Treatment/ Lifestyle
2. Rhonchi · LVF, Polyarteritis nodosa Modifications
These have been practice over the years, even
Abdomen when no drugs were available and their value
1. Hepatomegaly - Cardiac failure established. They help to control hyp ertension in
2. Palp able kidney lump - Polycystic kidney, some, but are useful as adjuvants to drug treatment
hypernephroma in almost all patients. They include the following:
3. Bruit over renal artery • Renal artery stenosis 1. Salt restriction: Modest sodium restriction
to up to 110 mmoles/day (2.4 g sodium or 6
4. Bruit over abdominal aorta - Abdominal aortic
g sodium chloride) is effective in controlling
aneurysm
hypertension in mild to moderate hypertension
Investigations because sodium and water retention is involved
in large proportion of hyp ertensives.
To assess target organ damage 2. Weight reduction:In overweight persons,
I. X-ray chest for heart size reduction of l kg may reduce 1.6/ l.3 mmHg
BP. It also modifies other CVS risk factors like
2. ECG for LV hyp ertrophy and evidence of IHD diabetes and dyslipidemia. BP is lowered by:
3. Echocardiogram for LV systolic and diastolic a. Reduced circulating volume which
functions reduces venous return and cardiac
4. Urinalysis • proteinuria>200 mg/day and output
hematuria suggest renal involvement. Further b. Reduced sympathetic activity and
investigations include serum creatinine, renal plasma nor-epinephrine
sonography, isotopic renogram, renal biopsy.
c. Reduction in hyp erinsulinemia
To Detect the Cause of Hypertension 3. Stop smoking: Smoking acutely raises BP.
1. X-ray chest In addition, it is an independent and most
important reversible coronary risk factor.
a. Rib notching suggests coarctation of aorta
Since tolerance develops to nicotine-induced
b. Mediastinal widening suggests aortic
hemodynamic effects, chronic smoking may
dissection
not be associated with high BP.
2. Imaging ofabdomen (Sonography, CT scan, MRI)
4. Diet:
to detect:
a. Polycystic kidney A. Lactovegetarian diet and high intake
of polyunsaturated fish oils have high
b. Tumour of kidney
potassium levels and lower BP by:
c. Renal calculi
i. Increased sodium excretion
d. Adrenal tumour
e. Pheochromocytoma ii. Decreased sympathetic activity
3. Urinary catechols or breakdown products iii. Decreased renin-angiotensin
(Metanephrine or VMA) - Pheochromocytoma secretion and direct dilatation of
4. Echocardiogram - coarctation of aorta renal arteries
5. IVP • for renovascular hypertension, kidney B. Adequate calcium, magnesium intake
tumours and stones should be maintained in the diet.
6. Aortography · for aneurysm and coarctation of C. Saturated fat and cholesterol intake
aorta should be reduced for overall
cardiovascular health.

51
PRACTICAL MEDICINE

5. Limit of alcohol intake to < l ounce/day of Nifedipine was the commonest used calcium
ethanol {24 ounces beer, 8 ounces wine or 2 blocker. Now Amlodipine is replacing
ounces 100-proof whiskey) it. Felodipine, nicardipine, nitrendipine
6. Relaxation: Various forms of relaxation like and dinidipine are other useful calcium
yoga, biofeedback and psychotherapy lower blockers. These drugs are especially useful
BP, especially in those with sympathetic in elderly hypertensives. Flushing, headache,
palpitations, edema and hypotension may
7. Regular exercise
occur.
II. Pharmacological Treatment
4. ACE Inhibitors: Renin released from the
l. Diuretics: Oral diuretics were the most widely kidney acts on circulating angiotensinogen
used anti-hypertensive agents. They are to produce angiotensin [, which is converted
effective alone in 50% of mild hypertensives. to angiotensin II by converting enzyme.
Thiazides are very effective. They are well Angiotensin II is a potent vasoconstrictor and
tolerated and need to be given only once it stimulatesaldosterone, which retainssodium
a day. They enhance the potency of other and causes hyper-tension. ACE inhibitors
anti-hypertensives. They act by reducing act by inhibiting the converting enzyme
extracellular fluid volume and cardiac output preventing the formation of angiotensin II
and they help to counteract the hypertensive and lowering ofBP. They also act by reducing
effect of high salt intake. They can aggravate the degradation of bradykinin · a potent
diabetes by suppressing release of insulin vasodilator, which lowers the BP.
due to hypokalemia. Hyperlipidemia,
ACE Inhibitors cause regression ofventricular
hyperuricemia, hypokalemia, hyponatremia,
hypertrophy, attenuation ofreperfusion injury­
hyp omagnesemia may occur. Now they are
induced ventricular arrhythmias, preload
usually used in combination therapy.
and afterload reduction and coronary vaso·
2. Beta blockers: Reduce cardiac output and dilatation. These drugs have no adverse effects
lower BP but raise the peripheral resistance oflipids, uric acid or glucose metabolism. They
on acute administration { which increases BP). lower the BP by 15-25% . Diastolic pressure
However, on chronic administration, BP falls is lowered more than systolic pressure.
to pretreatment levels. In mild to moderate Concomitant sodium restriction and diuretics
hyper-tension, it lowers the BP to less than further lowers BP by 15-25%.
90 mmHg in more than 50% patients. Drug
ACE Inhibitors are useful in renovascular
withdrawal, if needed, should be done slowly,
hyp ertension. High angiotensin II is however
or rebound hypertension may occur. They can
required to maintain adequate filtration
be combined with diuretics, calcium blockers,
pressure behind the stenotic lesion. ACE
ace inhibitors and vasodilators. They may
Inhibitors decrease the perfusion pressure and
precipitate bronchospasm, cardiac failure,
lead to azotemia. Thus, they are contraindicated
peripheral vascular disease, impotence and
in bilateral renal artery stenosis. These drugs
depression.
are useful in hyp ertensive diabetics because
3. Calcium Channel Blockers: Lower BP of neutral effect of carbohydrate metabolism.
by: In addition they decrease microalbuminuria.
a. N atriuresis and diuresis due to increased Captopril also improves insulin sensitivity.
GFR and decreased aldosterone It has a short duration of action and is used
b. Anti-angiotensin-11 effect for cardiac failure. Enalapril, lisinopril,
C. Direct negative inotropic effect which perindopril, ramipril, etc. are longer acting
lowers cardiac output ACE inhibitors and useful in hypertension.
Tissue specific ACE inhibitors like Quinapril,
d. Peripheral vasodilatation Ramipril, Perindopril, Fosinopril are available.

52
< 2 ) General Examination
5. Angiotensin II Blockers are useful in patients 2. Intravascular volume contraction: Hemorrhage,
with ACE Inhibitor-induced cough and in vomiting, diarrhea, burns, intestinal obstruction,
elderly hypertensives. Losartan, Irbesartan, peritonitis, etc.
Valsartan, Candersartan are available. 3. Anaphylaxis
6. Alpha Blockers: Adrenergic stimulation of 4. Gram negative septicemia
alpha-I receptors in the vascular smooth
muscles causes vasoconstriction and Clinical Features
hypertension. Alpha blockers attenuate I. Due to shock: Tachycardia, vomiting, fainting
vasoconstriction, and thereby decrease 2. Due to causative disease
vascular resistance and blood pressure. 3. In vasovagalattacks, hypotension with bradycardia
Prazosin was the first alpha blocker with 4. In postural hypotension, fall of BP occurs on
short duration of action. Terazosin and suddenly on assuming an erect posture from
doxazosin are longer acting, once a day alpha supine posture
blockers. The efficacy can be enhanced by
the concomitant use of diuretics. The most Treatment
dramaticadverse effect is the first dose postural l. Of the cause
hypotension/syncope.
2. Posture: The patient should be in lying position
Alpha blockers also have other beneficial with legs raised.
effects like lowering of lipids, regression 3. For vasovagal attacks: Atropine 0.6 mg IV
of left ventricular hypertrophy, enhancing
4. For anaphylaxis: Hydrocortisone hemi-succinate
insulin sensitivity (hence ideal for diabetic
I 00 mg IV, repeated as required
hypertensives) and relief of obstructive
5. For postural hypotension: This is best treated by
symptoms in benign prostatic hypertrophy.
advising the patients to assume the erect posture
7. Vasodilators: These drugs act on the arteriolar
slowly and to wear elastic stockings and abdominal
smooth muscles, causing vasodilatation and binder.
lowering of BP. However, reflex tachycardia
6. Vasoconstrictors: Dopamine, nor-epinephrine and
and increase in cardiac output limits its
ephedrine have been tried.
usefulness in severe coronary artery disease.
These effects can be reduced by combining 7. Salt: Adequate amount ofsalt (NaCl) in diet helps
hydralazine with beta blockers. Minoxidil to expand the plasma volume.
is the other vasodilator whose usefulness is 8. Fludrocortisone Acetate: (0.1 - 0.2 mg) causes fluid
limited due to hirsutism in females. Diazoxide retention and avoids postural fall of BP.
and nitroprusside are parenteral vasodilators
Chronic Hypotension
useful in hypertensive emergencies.
A number of healthy subjects have a systolic BP of
80-100 mm Hg, which is compatible with long life
20 > Hi�otension expectancy. 0nly some patients complain ofweakness,
lethargy, easy fatigability, dizziness and fainting on
Definition: Hypotension is diminished blood pressure.
assuming erect posture or standing inactive for long
This could be acute or chronic.
periods. This occurs due to interference with neural
Acute Recumbent Hypotension pathways between the vasomotor center and efferent
sympathetic nerve endings in the blood vessels and
Causes heart, so that the normal rise in cardiac output and va­
soconstriction on assuming erect posture are abolished.
l. Cardiovascular: Acute myocardial infarction,
pulmonary embolism, dissecting aneurysm,
ventricular tachycardia, cardiac rupture

53
PRACTICAL MEDICINE

Causes Treatment
I. Cardiac:· l. Mechanical: Elastic bandages over legs, head up
a. Low output cardiac failure position in bed etc.
b. LV dysfunction 2. Volume expansion with high fluid and salt intake
c. Cardiac tamponade 3. Fludrocortisone supplement (0.01 mg/day)
d. Constrictive pericarditis 4. Drugs:
e. Tight mitral stenosis a. Sympathomimetics: Ephedrine, ampheta­
mine, L-dopa
f. Left atrial myxoma
2. Supine hypotension of pregnancy b. Prostaglandin synthesis inhibitors like
indomethacin
3. Endocrine
c. Alpha 2 receptor agonists
a. Addison's disease
d. Partial Beta agonist (pindolol)
b. Myxedema
e. Erythropoietin
c. Hypopituitarism
f. Somatostatin analogue (octreotide) prevents
d. Serotonin secreting tumors splanchnic pooling after eating)
4. Neurogenic g. Midodrine for neurogenic causes
a. Diabetic neuropathy 5. Atrial pacing
b. Extensive lumbosacral sympathectomy
Shy-Drager Syndrome
c. Peripheral neuropathy
d. Tabes dorsalis This is chronic orthostatic hypotension with degenera­
tion ofCNS, mainly involving extra-pyramidal tracts,
e. Syringomyelia, Multiple sclerosis
basal ganglia and dorsal nucleus of Vagus. These pa·
5. Chronic idiopathic orthostatic hypotension tients have intact peripheral autonomic nervous system
Chronic Idiopathic Orthostatic but are unable to activate it. (In primary autonomic
Hypotension insufficiency there is depletion of nor-epinephrine
in the peripheral autonomic ganglia). In both these,
This occurs due to primary autonomic insufficiency catecholamine blood levels do not rise on standing,
due to degeneration ofcentral or peripheral autonomic although it may be normal at recumbency in chronic
nervous system. It is common in the elderly who may orthostatic hypotension but reduced in primary au­
develop syncope, hypotension, convulsions but no tonomic insufficiency.
tachycardia on standing. They may have associated
anhydrosis, loss of hair, diminished lachrymal and
salivary secretion, bladder atony and impotency.

54
1 > Proforma VIII. Eye : Kayser - Fleischer ring on slit lamp
Examination of cornea.
History IX. Miscellaneous: Bony tenderness, genitals.

I. Anorexia, nausea, vomiting, dysphagia, Alimentary System Examination


flatulence, eructation, retrosternal burning,
I. Oral cavity
water brash
A. Teeth C. Tongue
II. Diarrhea, constipation, clay stools, worms in
stools, mucus and blood in stools B. Tonsils D. Oropharynx
III. Abdominal pain, lump, and distension II. Abdomen:
IV. Hematemesis, melena, bleeding per rectum A. Inspection:
V. Jaundice, gynecomastia, loss of libido, loss of l. Skin
hair (for liver cell failure), reversal of normal 2. Shape of abdomen
sleep cycle. 3. Umbilicus
VI. Fever, weight Joss 4. Abdominal movements
VII. Alcohol, smoking
5. Pulsations
VIII. Past history of tuberculosis, malaria, kala-azar,
6. Dilated veins
leukemia, hemolytic crisis (sudden pallor and
dyspnea) sexual contact, drugs. 7. Peristalsis
8. Scars and sinuses
General Examination
9. Hernial orifices
I. Vital signs - TPR, BP B. Palpation:
II. Built and nutrition, BMI (body mass index)
I. Tenderness, guarding and rigidity on
III.Pallor, Clubbing, Nails (chalky-white nails superficial palpation.
koilonycnia) cyanosis, icterus.
2. Liver, spleen, kidney, gall bladder,
IV. Edema feet, lymphadenopathy, JVP colon, or any other lump (Its size,
V. Signs of liver cell failure: Scanty hair, palmar surface, borders, tenderness and
er ythema, spider nevi, parotid swelling, bruit}
gynecomastia, testicular atrophy, Dupuytren's 3. Fluid thrill
contractures, flaps (asterixis), paper money skin.
C. Percussion:
VI. Stigma oftuberculosis: Scars and sinuses in neck,
lymphadenopathy, phlyctenular conjunctivitis, I. Horseshoe and shifting dullness.
thickened spermatic cord, chest signs, etc. 2. Dullness over any lump, if palpable.
VIL Skin extoriations, ecchymosis or petechiae, 3. Renal angle tenderness (i.e. angle
cutaneous markers of GI malignancy. between one 12th rib & outer border
PRACTICAL MEDICINE

of erector spinae) seen in perinephric They can be differentiated as follows:


. abscess. 1. Fat : Pendulous abdomen with
D. Auscultation: symmetrical, globular, enlarged and
1. Peristalsis
accentuated cutaneous folds
2. Fluid : Fluid thrill, shifting and
2. Rub horseshoe dullness
3. Arterial Bruit or venous hum 3. Flatus: Generalized tympany more at
4. Puddles sign the periphery
E. Miscellaneous: 4. Feces: Generalized distension occurs,
1. Abdominal girth
more in the flanks. Fecal masses may
be felt.
2. PR examination 5. Fetus: Central dullness, tympany in
3. Proctoscopy the flanks, history of amenorrhea and
fetal parts may be palpable

2 > Examination
6. Full bladder: Tender, rounded, cystic
massmaybepalpableabovesymphysis
pubis, which may disappear after
A. Inspection micturition
The abdomen can be divided in to 9 regions by 7. Fatal new growth:
drawing 2 horizontal and 2 vertical imaginery a. Abdominal dullness overlying the
lines. The 2 vertical lines are drawn by joining growth
mid clavicular point to the mid inguinal point. b. In ovarian growth, the distance
The upper horizontal line is drawn at the lower between the umbilicus and
most bony point of the rib cage, usually the symphysis pubis is greater than
9th or 10th costal cartilage (Sub costal plane • that between the xiphisternum
corresponds to the body ofL3 vertebra). The lower and umbilicus
horizontal line is drawn at the upper border of
the tubercles of the iliac crests (Trans tubercular
plane - corresponds to the upper border of LS
vertebra). The 9 quadrants are shown in Figure.
I. Shape of Abdomen : The shape of the
abdomen in most normal persons with
normal musculature is scaphoid or boat­
shaped i.e. the abdominal wall sinks slightly
within the bony margins of the abdominal
surface.
In every muscular person, the lateral
margins of the rectus muscle is visible in
the center. Usually the medial edges of both
the recti are contiguous. However they may
be separated as a congenital defect, after
pregnancy or with obesity and ascites. This
is called divarication of recti. Distension of
the abdomen occurs due to fat (obesity),
fluid (ascites), feces, flatus, fetus, full
urinary bladder and (fatal) new-growth. Fig 3 1 lnspect,onofAbdomen-9Quadrants

56
( 3) Abdomen

Generalized distension occurs


.in ascites, obesity and patients
with excessive flatus. Localized
distension occurs with individual
vis cero m eg a l y a n d w i t h
neoplasms, e.g. hepatomegaly
produces abdominal distension
in the right hypochondriac
region whereas full bladder
produces marked distension of
hyp ogastrium.
Scaphoid or sunken abdomen
is seen with starvation and
malignancy, especially of stomach
and esophagus.
III. A bdomi nal Movements: Normally
II. Umbilicus: Normal umbilicus is usually
the abdominal wall bulges during
inverted and situated centrally in the
inspiration and falls during expiration.
mid-abdomen. The distance between the
In diaphragmatic paralysis the abdomen
xiphisternum and the umbilicus is equal
bulges during expiration. In peritonitis,
to the distance between the umbilicus and
the abdominal movements are absent.
symphysis pubis.
IV. Pulsations: Normally pulsations are not
In ascites, the distance between xiphisternum
visible over the abdomen. They may be
and umbilicus is greater than that between
visible in the following conditions:
umbilicus and symphysis pubis, whereas
in ovarian tumor the distance between 1. Aortic pulsations are visible in the
xiphisternum and umbilicus is less than that nervous, anemic individual.
between umbilicus and symphysis pubis. 2. Aortic aneurysm produces expansile
In ascites, the umbilicus is transversely pulsations in any position.
stretched (smiling) or flattened or everted 3. Transmitted pulsations from a tumor
whereas in obesity, the umbilical cleft is overlying the aorta disappear in knee­
deeper than normal. elbow position because the tumor falls
Everted umbilicus may occur with away from the aorta in that position.
hemiation of bowel or fat into the widened This is not so ifthe tumor is adherent
umbilical ring. Sometimes, umbilicus to the aorta.
may exude fluid e.g. ascitic fluid in 4. Right ventricular pulsations are
massive ascites or feculent material in seen only in the epigastrium and
enteric fistulae, or clear fluid in patent correspond with apex beat
urachus (crying umbilicus). A faint blue 5. Congestedliver, in addition, produces
discolouration around the umbilicus pulsations posteriorly.
(Cullen's sign) or in one or both flanks
V. Dilated Veins: Suggest venous obstruction.
(Grey Turner's sign) may occur in acute
hemorrhagic pancreatitis or ruptured When dilated veins are present, the
ectopic pregnancy. Cherry red swelling of direction of the blood flow can be found
the umbilicus suggests inflamed Meckel's by emptying (milking) a section of the vein
diverticulum. and pressing each end of the emptied part
with a finger. One finger is released and the

57
PRACTICAL MEDICINE

in all directions away from the umbilicus.


They represent opening of anastomosis
between portal and systemic veins.
VI. Peristalsis : Peristalsis is best elicited by
patiently observing the abdomen of the
patient. If it is not visible, an attempt to
visualize it should be made either by making
the patient swallow fluids or by applying a
Fig 3 3 Dilatedveinsovertheabdomen Left Inferior sharp tap with the fingerover the abdominal
vena cava obstruction {flowfrom below upwards) wall.
Middle· Supenorvena cava obstruction (flow from
above downwards). Right. Portal ve1 n obstruction (caput Peristaltic wave of the stomach is seen in
medusae)
. � -
pyloric stenosis in the epigastrium and
left hypochondriac region, moving from
left to right. Peristaltic wave of the large
intestine (transverse colon) is seen in the
same region but moving from right to left.
Peristaltic wave of small intestine is seen
in a ladder pattern down the centre of the
abdomen.
VII. Hernial Sites: The hernial sites in the groin
should be seen for any swelling. If there is
no swelling, the patient should be asked
to stand up, turn his head to one side and
cough. If there is an impulse on coughing
it suggests hernia.
filling of the vein is noted. Similarly, the To differentiate between femoral and
other finger is released and filling of the inguinal hernia, the index finger of the
vein is noted. Blood enters more rapidly examiner is placed on the pubic tubercle
and fills the vein from the direction of the (traced up along the tendon of adductor
blood flow. longus) and the patient asked to cough. If
In inferior vena cava obstruction there the impulse is medial and above the index
will be dilated veins on the sides with flow finger it is inguinal hernia. If the impulse
of blood from below upwards. This occurs tends to bulge straight out through the
because the blood bypasses the inferior posterior wall of the inguinal canal, it is
vena cava and travels from the lower limbs direct, whereas if it travels down obliquely
to the thorax via the veins of the abdominal along the inguinal canal, it is indirect.
wall. These veins are anastomotic channels VIII. Skin Over the Abdomen: Smooth and
between the superficial epigastric vein and glossy skin indicates abdominal distension
circumflex iliac veins below and the lateral whereas wrinkled skin suggests old
thoracic vein above conveying the diverted distension which has been relieved.
blood from the long saphenous vein to the
Abdominal striae (stretch marks) represent
axillary vein.
the rupture of subepidermal connective
In portal vein obstruction, the engorged tissue as a result of recent or past
veins are centrally placed and may form abdominal distension. It is seen commonly
a cluster around the umbilicus (caput following pregnancy, in obesity, in massive
medusa). The blood in these veins flows ascites and following corticosteroid

58
( 3 )Abdomen
therapy. When they first form, the striae are conditions, the patient complains ofsevere
reddish or pink. If the state of distension pain (e.g. appendicitis).
stabilizes or the cause regresses, the colour II. Guarding: Abdominal guarding is due to
fades to white. muscular contraction, which often occurs
B, Palpation as a part of the defense mechanism over
a tender region. If the patient is put in a
For palpation of the abdomen, the patient must comfortable position and his mind set at
lie on his back, shoulders raised slightly and legs rest by explaining that no undue pain will be
flexed to relax the abdomen. He should keep his caused by the examination, the abdominal
mouth open and breathe quietly and deeply. The muscles gradually relax.
abdomen is palpated with the flat of the hand III. Rigidity: Abdominal rigidity is due to
initially, but the fingers are used to locate the muscular contraction, which occurs as a
margins of any viscera or tumor. part of the defense mechanism over an
I. Tenderness: Tenderness is pain on pressure. inflamed organ. It cannot be voluntarily
It is commonly found in inflammatory relaxed. It occurs in the following:
lesions of the viscera and the surrounding 1. Perforation of a hollow organ
peritoneum.
2. Peritonitis
The site of tenderness often suggests the
diagnosis 3. Acute pancreatitis or cholecystitis
1. In the epigastrium - Peptic ulcer 4. Intestinal strangulation
2. In the right hypochondriurn - Hepatitis, 5. Thrombosis of superior mesenteric
cholecystitis artery
3. In the right iliac fossa - Appendicitis
6. Ruptured ectopic gestation
(Mc Burney's Point) 7. Twisted ovarian cyst or torsion of
4. Purely visceral pain such as gastric or fibroid
intestinal colic is not associated with Pancreatobiliary secretions are more
any tenderness. irritating to the peritoneum than bacteria
Rebound tenderness can be elicited by are, and so board-like rigidity suggests
exerting a firm pressure with the hand a chemical peritonitis most commonly
and releasing it. In deep seated, subacute from perforated gastric or duodenal ulcer.
Bacterial peritonitis rarely produces board­
like rigidity until late. It usually causes
increased resistance to compression.
IV. Viscera
A. Liver: The patient must be lying in
the supine position with hip and knee
flexed, to relax abdominal muscles.
The examiner moves his right hand
from the right iliac fossa gradually
upwards until a sense of increased
resistance is noted. The size of the liver
must be recorded as fingerbreadths
or centimeters below right costal
margin. The liver edge is accurately
Fig 3 5 S1teoftendernessin I l) Hepat1t1sandcholecyst1t1s,
located by the fingertips. It is normally
(2) Peptic ulcer,(3)Append1c1t1s and (4) Col1t1s

59
PRACTICAL MEDICINE

from the right iliac fossa to the left


hypochondriac region. The edge
of the spleen may be felt on deep
inspiration.
2. Bimanual: The patient is put in
the right lateral position, one
hand of the examiner is put over
the lower chest and the spleen is
palpated with the other hand. A
soft spleen, which may be missed
by the classical method, may be
palpated by this method.

3. Hooking: The patient is put in


sharp, firm and regular. The surface right lateral position and the
ofthe liver is palpated next. Normally examiner stands on the left side
it is smooth. An irregular nodular and feels the spleen by hooking his
surface indicates cirrhosis. Liver may fingers over the left costal margin.
be enlarged and pulsatile in tricuspid
regurgitation.
B. Spleen can be palpated by following
methods:
1. Classical: The patient is put in
the supine position and palpated

Fig. 3. IO: PJlf),1l1on of Sµlecn - Hooking Method


- - -- -- ---- - . ..

4. Dipping: This method is used


when there is severe ascites
which may mask an enlarged

60
( 3) Abdomen

spleen. The patient is put in the Causesofsplenomegaly: (Refer Pg.67)


supine position and the examiner C. Gall bladder: The gall bladder is
palpates as in the classical method palpated in a similar manner as liver.
except that he dips his fing-ers into Normally it is not palpable. When
the abdomen with each palpation, distended, it is palpated as a firm,
so that the fluid is displaced smooth, rounded or globular swelling
temporarily to the side. This with distinct borders just lateral to
facilitates palpation of the spleen. the rectus abdominis muscle. Its
upper border merges with the lower
border ofliver or disappears beneath
the costal cartilage and hence is not
usually felt.
Causes of enlarged gall bladder:
l. Carcinoma of the head of
the pancreas and malignant
obstruction of the common bile
duct. This is associated with
jaundice (courvoisier's law).
2. Mucocele of the gall bladder due
to impaction ofa stone at the neck
Splenomegaly (Enlarged Spleen)
of the gall-bladder. Here there is
Table 3.1 : Hackett's Classification of no jaundice
Splenomegaly
3. Carcinoma of the gall bladder
Grade Stage Examination
D. Kidneys: The left kidney is palpated
0 Not palpable by keeping the left hand posteriorly in
Mild Just palpable by bimanual method the loin and the right hand anteriorly
Moderate 2 Mid-way between costal margin and in the left lumbar region. Then the
umbilicus patient takes a breath, the left hand is
Moderate 3 Upto umbilicus
pressed forwards and the right hand
backwards, upwards and inwards. The
Severe 4 Between umbilicus and pubic
symphysis
right kidney is likewise palpated on
the right side. Normally the kidneys
Severe 5 Upto pubic symphysis
are not palpable unless placed low in
position or enlarged. Its lower pole
is felt as a rounded firm swelling
between both the hands (bimanual
palpation) and can be pushed from
one hand to the other (ballotable).
E. Abdomen: Doughy feel of abdomen
in TB peritonitis.
Mild splenomegaly: Just palpable
Moderate: Easily palpable,but not C. Percussion
reaching umbilicus Uniform enlargement of the abdomen may be
Massive: Extending up to umbilicus because of gas or fluid in the abdomen. In the
or beyond former there is tympanic note on percussion
while in the latter there is dullness.

61
PRACTICAL MEDICINE

1. Shiftingdullness: This isseen with moderate


ascites. The abdomen is percussed starting
from the midline. The upper border offluid
in each flank is determined. The pleximeter
Tympanic note
finger is kept in position on one flank and
(Gas)
the patient is turned to the other side. After
waiting for about 15 seconds, percussion at
Dull note
the same point produces a tympanic note
(Fluidl
as the intestines float up. The abdomen is
then percussed towards the other flank.
There is an increased width of dullness on
the other side due to shift of fluid.
Fig 3 14 Horseshoe shaped dullness on percussion
!
3. Fluid thrill: This is seen in tense ascites.
One hand is kept over one flank and a sharp
flick is delivered with the other hand over
the opposite flank. The patient is asked to
keep ulnar edge of one hand in the midline.
A tap is felt by the palpating hand in case
of tense ascites.

2. Horseshoe shaped dullness: This is seen


with moderate ascites. The abdomen is
percussed in various directions from the
umbilicus outwards. Area of dullness
appears horse-shaped with a concave upper
border. This is because fluid accumulates
in the dependent parts and the intestines
float up.

4. Puddles Sign: It is to be elicited in minimal


ascites (150 ml). The patient is asked to go
"on all fours" so the fluid collects in the
mid-abdomen which is dependant. One
flank is lightly flicked with one hand and
the most dependant part is auscultated.
The chestpiece of the stethoscope is then
moved to the opposite flank. A change in the
intensity of the note heard indicates fluid.
In addition to determining fluid, percussion
helps to delineate the outline ofan enlarged

62
( 3) Abdomen

viscera or abdominal tumor. It helps to space in the midclavicular line in patients


differentiate enlarged spleen (dull note) with amebic abscess ofliver or any abscess
from an enlarged left kidney (resonant on the superior surface of liver. The liver
note because of the intervening colon). dullness is lower in the sixth or seventh
----, right intercostal space in emphysema, right­
sided pneumothorax, when there is air in
the peritoneal cavity, acute yellow atrophy
of the liver and in terminal cirrhosis.

D. Auscultation
Auscultation of the abdomen is done for the
following:
1. Peristalsis : These are intestinal sounds
generated by contractions of the muscular
walls of the gut and the resultant vibration
of the gut wall produced by movement of
a gas-fluid mixture through the gut. These
bowel sounds (peristalsis) persist in the
5. Tidal Percussion : The upper border of fasting state due to the presenceofintestinal
the liver can be accurately determined by secretions and swallowed air. Loud bowel
percussion. sounds (hyperperistalsis) accompanied
Liver Span: Percussion is started anteriorly by abdominal distension and crampy
in the right midclavicular line from second abdominal pain suggests partial bowel
intercostal space downwards and repeated obstruction. Absence of bowel sounds for
in the anterior, mid and posterior axillary at least 5 minutes strongly suggests bowel
lines and the scapular line posteriorly. atony or ileus. Borborygmi refers to audible
The normal liver dullness is in the fifth peristalsis which can be heard even without
space in the midclavicular, seventh space a sthethoscope.
in the anterior axillary and ninth space in 2. Arterial Bruit: These are variable harsh
the scapular lines. The normal liver span sounds in tempo with the pulse due to
in an adult as judged by liver dullness turbulence in arterial flow. This may
measures 10-12 cm in men and 8-11 cm occur by unusually acute angulations at
in women. The upper border of the liver arterial branch points, arteriosclerotic
may be percussed in the fourth or third plaques, extreme tortuosity of an artery,
compression ofan artery or massive blood
flow through very vascular tumors like
hemangioma or hepatoma. Bruits over
the liver suggests very vascular tumor like
hepatoma or angioma. Similarly, over the
spleen it suggests vascular tumor. Bruit
over the aorta, if soft, has no significance.
However a loud bruit suggests aortic
aneurysm, atherosclerosis or extreme
tortuosity of the aorta, Bruit over the
kidneys in the flanks suggests renal artery
stenosis.

63
PRACTICAL MEDICINE

3. Venous Hum: Venous hum is continuous, Small vessels in the skin associated with arterial spiders
softer and lower pitched than bruit. It have been compared to the silk thread in American
signifies portal systemic shunting ofvenous paper money. Therefore, the skin is called paper
flow when portal flow is obstructed. It money skin.
is usually heard over the liver area and
umbilicus. Causes
1. In alcoholics 5. Pregnancy
Fetor Hepaticus
2. Cirrhosis 6. Rheumatoid arthritis
Definition: This is the fecal smell of the breath similar
3. Viral hepatitis 7. Thyrotoxicosis
to that of a freshly opened corpse of a mouse.
4. Normal persons especially children
Mechanism: Normal demethylating process is inhib­
ited by liver damage. Hence, methionine is converted Mechanism: The selective distribution of spider nevi
to methyl mercaptan, which gives the typical smell. is not understood.
1. Exposure of upper parts of the body to certain
Causes elements may damage the skin so that it is
I. Acute liver cell disease/failure: Poor prognostic susceptible to develop spider nevi when an
sign and often precedes coma. appropriate internal stimulus exists.
2. Extensive portal collateral circulation 2. Estrogen exce�s may be responsible. It forms
arterioles of the endometrium in uterus during
Spider Nevi pregnancy, which resembles spider nevi.
Synonyms: Arterial spider, Spider telangiectasis, Spider Significance : Appearance of fresh spiders suggests
angioma progression of liver damage. Spider nevi disappear if
Definition: An arterial spider is a central arteriole, liver function improves or blood pressure falls due to
from which numerous small vessels radiate resembling shock or hemorrhage.
a spider's legs. Palmar Erythema
Sites: Arterial spiders are found in the territory of the
Definition : Palmar erythema is bright red warm
superior vena cava. They are commonly seen on the
face, neck, forearm and shoulder. palms. The thenar and hypothenar eminences and
soles offeet are especially erythematous. The erythema
Appearance: They range in size from 3 to 15 mm in blanches on pressure.
diameter. They are pulsatile and blanch on pressure.
When the skin is stretched or compressed they fill Causes
from the centre to the periphery.
1. In alcoholics 6. Leukemia
2. Cirrhosis 7. Pregnancy
3. Viral hepatitis 8. Febrile diseases
4. Thyrotoxicosis 9. Familial
5. Rheumatoid arthritis
Significance : Palmar erythema is not so frequently
seen in cirrhosis, as are vascular spiders.
Asterixis (Flaps)
Definition : Asterixis are rapid flexion-extension
movements at metacarpophalangeal and wrist joints.
Therefore they are seen as a flapping tremor.
Fig. 3 18 Spider nevi
Significance : In liver disease, it indicates that the
patient is in hepatocellular failure.
64
( 3> Abdomen

Demonstration : The patient is asked to stretch out IV. Biliary obstruction:


his hands in front ofhim, parallel to the ground, with A. Gall stones
fingers extended and abducted.
B. Strictures
Causes V. Degenerative and Infiltrative disease:
1. Hepatocellular failure A. Fatty E. Hodgkin's disease
2. Uremia B. Amyloid F. Leukemias
3. Respiratory acidosis - CO 2narcosis C. Gaucher's disease G. Multiple myeloma
4. Dr ugs - anticonv ulsants, (ph enytoin, D. Niemann Picks disease
carbamazepine and phenobarbitone). VI. Tumors:
5. Brain stem lesions A. Primary- Hepatocellular, cholangiocellular
sarcomas

3 > He�atomegalr____
B. Secondary
VII. Toxic: Alcohol, arsenic, phosphor ous,
Definition : Hepatomegaly means enlarged liver. An chlorpromazine
enlarged liver may not always be palpable if it is slightly
Painful Hepatomegaly
enlarged and a palpable liver is not always enlarged.
I. Cardiac failure
Causes
2. Viral hepatitis
I. Infective: 3. Hepatic amebiasis
A. Along the biliary tree: Cholangitis. 4. Pyemic abscess of liver
B. Along the portal vein: 5. Hepatoma
1. Amebiasis 6. Actinomycosis of liver
2. Schistosomiasis 7. Weil's disease (Leptospirosis)
3. Bacterial infections Pulsatile Liver: Tricuspid insufficiency
C. Along the hepatic artery: Bruit over the Liver
1. Bacterial: Typhoid, brucellosis, 1. Hepatoma
tuberculosis
2. AV malformation
2. Viral: Infective hepatitis, infectious
mononucleosis Differential Diagnosis
3. Spirochetal: Syphilis, Weil's disease I. Viral Hepatitis (Refer Pg. 71)
4. Protozoal: Malaria, kala azar A. Prodromal symptoms of gastrointestinal
5. Fungal: Actinomycosis, upset e.g. anorexia, abdominal discomfort
histoplasmosis B. Fever, malaise
6. Parasitic: Echinococcus C. Dark colored urine
II. Congestive: D. Jaundice on 3rd or 4th day
A. Cardiac failure E. Enlarged tender liver with mild intercostal
tenderness
B. Cardiomyopathy
F. Palpable spleen in 25% cases
C. Constrictive pericarditis
II. Amebic Liver Abscess
D. Budd Chiari syndrome
A. Moderate to huge, tender liver
III. Cirrhosis (in early stages)
B. Fever with rigors

65
b
PRACTICAL MEDICINE
C. Rt. upper abdominal tenderness VI. Hydatid Cyst
D. Blood and mucus in stools in the past A. The liver is non-tender(unlike liverabscess).
E. Shift ofliver dullness upwards Ifcyst is on the surface, rounded, localized,
F. Investigations-moderate leucocytosis, smooth swelling (unlike carcinoma and
diminished movements of diaphragm on syphilis) is present
screening, aspiration of anchovy sauce B. When the cyst is tense there may be a
material from liver with demonstration of hydatid th rill
trophozoites in it. C. No jaundice or splenomegaly is present
Ill. Pyemic Liver Abscess D. There is history ofcontact with dogs
A. Signs of septicemia E. Urticaria may be present if hydatid fluid is
1. High fever with rigors and profuse absorbed
sweating F. Investigations: Eosinophilia, positive
2. Anemia, tachycardia, leucocytosis, complement fixation test, calcification of
positive blood culture cyst wall demonstrated by radiology and
B. Local signs positive Casoni's test
1. Pain, tenderness, edema and redness VII. Congestive Hepatomegaly
over lower right intercostal spaces A. Slight to markedly enlarged, firm, smooth,
2. Marked tender hepatomegaly tender liver, pulsatile if there is tricuspid
3. Shift ofliver dullness upwards incompetence
IV. Malaria: (Refer Pg. 90) B. Other evidence of cardiac failure: Edema
A. Fever with chills and rigors, coming down offeet, raised JVP and ascites
with sweating. Paroxysms offever every 72 C. In severe cases, dyspepsia and jaundice
hours with Pl. malariae and 48 hours with D. Evidence ofcardiac lesion
the other types
VIII. Cirrhosis ofLiver: (Refer Pg. 82)
B. Splenomegaly, mild to massive, always
present when liver is enlarged Signs oflivercellfailure: Pa!mar erythema,
A.
spider nevi, gynecomastia, testicular
C. Anemia
atrophy, flapping tremors, ascites, jaundice,
D. Peripheral blood smear and bone marrow Dupuytren's contracture, parotid gland
show presence ofparasites swelling, alopecia, loss oflibido.
V. Kala Azar: (Refer Pg. 95) B. Evidence of portal hypertension:
A. Long continued fever Splenomegaly, ascites (out of proportion
B. Hepatosplenomegaly to edema of feet), hematemesis, dilated
C. Anemia, weight loss veins over chest well, bleeding per rectum
D. Dark pigmentation IX. Hemochromatosis
E. Demonstration of Donovan bodies in A. A triad ofcirrhosis, diabetes mellitus and
reticulo-endothelial cells e.g. in bone pigmentation ofskin may be present.
marrow, liver and spleen B. Ascites is rare
F. Serological tests - Napier's Aldehyde test, C. Cardiac complications may occur
Antimony, Brahmachari's and W.K.K.
D. Increased stores on iron in serum and
complement fixation test, immuno­ reticuloendothelial cells
fl uoscent. Antibody test, Indirect
Hemogglutination test and ELISA may be X. Malignancy
positive A. Markedly enlarged liver with upward

66
{ 3 } Abdomen

4 > S�lenomegal)!____
increase of liver dullness, a hard often
irregular. edge, with uneven knobby hard
nodules, sometimes umbilicated. Sudden Definition : Splenomegaly is an enlargement of the
enlargement of the nodule is due to spleen (Refer Pg. 55). The spleen has to be two and a
hemorrhage halftimes its normal size to become palpable; therefore
B. Pain in the hepatic region and over the an enlarged spleen is not always palpable. In ptosis of
right shoulder. Dragging and fullness in spleen, it is palpable, though not enlarged.
the right hypochondrium
Evidence of Enlargement of Spleen
C. Jaundice - deep yellow to deep olive green
1. Predominant left sided abdominal distension,
D. Cachexia, loss of weight, and dry shriveled
if massive splenomegaly
skin may be present
2. Splenic mass moves downwards on inspiration
E. Ascites and edema of legs may occur
3. A notch is felt on the anterior border
F. There may be evidence of primary or pre­
4. Left abdominal pain if massive splenomegaly
existing cirrhosis
XI. Biliary Obstruction Causes
(Commonly due to gall stones):
I. Infective:
A. Deeper jaundice than in cirrhosis
A. Bacterial: Septicemia, SBE, typhoid,
B. History of colicky pain syphilis.
C. Clay-coloured stools with dark urine B. Viral: Infective hepatitis, infectious
D. Fever with rigors due to cholangitis mononucleosis
XII. Alcoholic Liver Affection: C. Protozoa/: M a l a r i a, k a l a azar,
A. Smooth, tender, enlarged and firm liver is trypanosomiasis
present. D. Fungal: Histoplasmosis
B. Right upper abdominal pain, anorexia, II. Congestive:
nausea and vomiting may occur. A. Suprahepatic:
C. There may be profound weakness, jaundice, 1. Congestive cardiac failure
spider nevi and palmar erythema.
2. Constructive pericarditis
XIII. Leukemias (Refer Pg. 102)
3. Budd Chiari syndrome
XIV. Hodgkin's Disease (Refer Pg. 107)
B. Hepatic:
XV. Amyloidosis
1. Cirrhosis
A. Evidence of chronic wasting disease
2. Schistosomiasis
B. Liver large, smooth, rubbery and non-
3. Sarcoidosis
tender
4. Congenital hepatic fibrosis
C. Jaundice, ascites and generalized edema
C. Intrahepatic: Portal vein thrombosis - Extra
D. Splenomegaly
hepatic portal HT.
E. Albuminuria (kidney affection) and
III. Blood Diseases:
diarrhea (gastrointestinal affection)
A. Polycythemia rubra vera
F. Congo Red test is positive. Liver biopsy,
kidney biopsy and rectal biopsy for amyloid B. Hemolytic anemia - Thalassemia
infiltration may also be positive. C. Leukemias
D. Lymphoma
E. Myelofibrosis

67
PRACTICAL MEDICINE

Table 3.2: Distinguishing Features Types of Splenomegaly


between Splenomegaly and other Left
I. Massive Splenomegaly:
Sided Abdominal Masses
A. Kala azar , chronic malaria
Spleen Kldmw
1. Enlargement Forward and In the loin
B. Chronic myeloid leukemia
inward C. Extrahepatic portal hypertension
2. Notch Present Absent D. Myelofibrosis
3. On inspiration Moves well Moves less II. Moderate Splenomegaly:
4. Hand insinuation Not possible Possible A. All the above as in I
between lump and
lowercostal margin B. Hodgkin's disease, leukemias; lymphomas,
5. Loin fullness Absent Present polycythemia rubra vera
6. Percussion note Dull Resonant C. Hemolytic anemias
D. Biliary cirrhosis
Spleen Maltgnant growth of
stomach Ipancreas E. Hemochromatosis
1. Edge, notch Present Absent F. Tumors and cysts
2. Crossing to If splenic In pancreatic G. Tuberculosis
right side enlargement is enlargement the
Ill. Mild (slight) Splenomegaly:
severe, it crosses the tumor crosses the
midline atorbelow midline above the A. All the above as in I & II
the umbilicus umbilicus
B. Acute infections: Typhoid, septicemia, IE
Spleer, Carcinoma Splenic IV. Acute Splenomegaly:
flexure of colon
A. Acute infectious fevers: Typhoid, malaria,
1. Direction of More forwards Transverse IE
enlargement and inwards
B. Injury: Hematoma, ruptured spleen
2. Edge, notch Present Absent
3. Percussion Dull Resonant
C. Vascularcauses:Splenicinfarct, thrombosis
(rarely dull) of splenic vein
4. Intestinal Abdominal Blood and fullness D. Connective t issue disorders: SLE,
symptoms mucus in stools, rheumatoid arthritis, Felty's and Still's
alternating diarrhea
disease
and constipation
5. Lymphadenopathy Absent Left su praclavicu lar
E. Tumors and cysts
glands may be V. Hepatosplenomegaly:
palpable
A. Infective: Malaria, kala azar, infective
6. Barium studies Normal Show pathological hepatitis, IE
lesion
B. Hematological conditions: Leukemia,
IV. Infiltrative and degenerative disorders: lymphomas, Hodgkin's disease, chronic
A. Gaucher's disease hemolytic anemias
B.
Niemann Picks disease C. Congestive: CCF, pericarditis, Budd Chiari
C.
Amyloidosis syndrome and portal hypertension
D. Storage disorders: Glycogen storage,
V. Neoplastic: Hemangiomas, sarcomas, cysts,
metastasis Amyloidosis
VI. Miscellaneous: VI. Hepatosplenomegaly with Lymphadenopathy
A. Connective tissue disorders. A. Acute Leukemia
B. Rupture of spleen and hematoma.
B. Hodgkin's and Non-Hodgkin's Lymphomas

68
( 3 )Abdomen

C. Infectious mononucleosis D. Rising Wida! test titre, and positive blood


D. Dissemin·ated Tuberculosis culture help to confirm the diagnosis
E. HIV infection or AIDS IV. Portal Vein Occlusion
F. Sarcoidosis There is sudden onset of severe abdominal pain,
hematemesis, tender splenomegaly and ascites
VII. Splenomegaly with Pallor and Icterus:
V. Polycythemia Vera
A. Hemolytic anemia
A. Brick red colour of skin, cyanosis of lips
B. Cirrhosis ofliver with portal hypertension
and ears
VII. Splenomegaly with Petechiae and Ecchymosis:
B. Hepatosplenomegaly
A. Acute Leukemia, blast crisis in CML and
C. Nervous symptoms
CLL stage IV
D. Hemorrhages
B. SBE
VI. Hemolytic Anemias
C. SLE
A. Anemia, jaundice, splenomegaly
Differential Diagnosis B. Pigmented gallstones
The following are discussed under hepatomegaly: C. Ulcer over the malleoli
1. Viral hepatitis VII. Felty's Syndrome
2. Pyemic liver abscess Felty's syndrome is characterized by chronic
3. Malaria, kala azar splenomegaly with chronic rheumatoid arthritis
4. Hydatid cyst and neutropenia. There may be associated
5. Congestive hepatomegaly hepatomegaly, lymphadenopathy, weight loss,
pigmentation of skin and ulceration oflegs.
6. Cirrhosis
7. Leukemias, Hodgkin's disease
vm. Systemic Lupus Erythematosus
8. Amyloidosis A. General symptoms: Fever and weight loss
I. Infective Endocarditis (IE) B. Skin lesions: Erythema, purpura, urticaria,
malar rash and subcutaneous nodules
A. Feature of septicemia
B. Embolic episodes C. Polyarthritis
C. Cardiac lesions D. Hepatosplenomegaly
II. Infectious Mononucleosis E. Other system involvement
A. Onset with fever, sore throat, rash, pruritus F. L.E. cell demonstration.
B. Hepatosplenomegal with G. ANA and double strand DNA test positive
lymphadenopathy
C. Mild transient jaundice may occur
D. Paul Bunnell test may be positive (I :56)
E. Typical peripheral smear: Lymphocytosis
and Downey cells
III. Enteric Fever (Typhoid): (Refer Pg. 98)
A. Continuous fever with stepladder rise
B. In second week rose spots may appear
C. In third week relative bradycardia with
dicrotic pulse, soft splenomegaly and
gastrointestinal disturbances occur

69
PRACTICAL MEDICINE

5 > Ascites B.
C.
Bile
Chylous
Definition : Ascites is the accumulation of free fluid D. Myxedema
in the peritoneal cavity
Table 3.3 : Transudate and Exudate
Diagnosis
,.
Transudate Exudate
I. Generalized distension of abdomen with more Process Passive Active
fullness in the flanks 2. Serous structures Others Only local
II. Shifting dullness can diagnose 500 ml fluid 3. Appearance Clear Clear/turbid
III. Horse-shoe-shaped can diagnose l litre fluid
4. Specific Gravity < 1.015 > 1.015
IV. Fluid thrill seen in tense ascites
5. Proteins <3gm/dl >3gm/dl
V. Other signs:
6. Cells Few Polymorphs or
A. Transverselystretchedumbilicus ('laughing' mesothelial Lymphocytes
umbilicus) cells
B. Divarication ofrecti 7. Clot formation Nit Present
C. Tense and shiny skin 8. Gradient" ;.:1.1g/dl < ,., g/dl
D. Widened subcostal angle *Serum albumin minusasciticfluidalbumin (SAAG)
E. Lower ribs pushed outwards and upwards Routine exudate /transudate system is no longer used in
VI. Diagnosis of small quantity of fluid (Puddle ascites
sign): The patient is put in knee chest position It is advisable to calculae SAAG to classify ascite as follows:
so that the fluid gravitates down to the anterior
1. High SAAG ascites (SAAG � 1.1 g/dl) - It indicates
abdominal wall. The stethoscope is placed over portal Hypertensive Ascites with sensitivity &
this and the anterior abdominal wall is flicked specificity of 97%. Causes: i) cirrhosis of liver; ii) cardiac
for a puddle sound. This can diagnose even l SO cirrhosis; iii) Budd Chiari syndrome; iv) veno occlusive
disease; v) portal vein thrombosis and vi) Fulminant
ml fluid.
liver failure
Causes 2. Low SAAG ascites (SAAG < 1.1 g/dl). Causes :
i) Tuberculosis; ii) Nephrotic syndrome; iii) pancreatitis;
I. Transudates iv) biliary ascites; v) peritoneal carcinomatosis
A. Cardiac failure F. Portal hyp ertension
B. Hypoproteinemia G. Epidemic dropsy Mechanism of Ascites Production
C. Anemia H. Polyserositis l. Increased hydrostatic pressure intravascularly
D. Beriberi I. Meigs syndrome 2. Decreased osmotic pressure intravascularly due
E. Nephrotic syndrome to hypoproteinemia
II. Exudates 3. Increased osmotic pressure extravascularly
A. Peritoneal disease 4. Increased lymphatic pressure
l. Infections: Tuberculosis, bacterial,
Causes of Hemorrhagic Fluid
fungal and parasitic infections
2. Neoplasms l. Trauma of thoracic duct
B. Collagen disorders 2. Parasite infections e.g. filariasis
C. Eosinophilic gastroenteritis 3. Tuberculosis
D. Gynecological: Endometriosis, struma ovarii 4. Thrombosis of subclavian vein
III. Miscellaneous 5. Malignancy involving thoracic duct
A. Pancreatic

....
70
( 3) Abdomen

causes of Purulent Fluid D. Hepatomegaly with ascites


E. Pericardial knock
1. Abdominal infections.
F. Calcification of pericardium on X-ray. On
2. Penetrating wound ofabdomen
screening poor pulsations
3. Pyemia and septicemia
VI. Budd-Chiari Syndrome
4. Rupture or perforation of an organ (Hepatic vein thrombosis)
5. Ruptured amebic liver abscess A. Large, tender liver
6. Pelvic inflammatory disease B. Absent hepatojugular reflux
Causes of Ascites Disproportionate to C. Biopsy: Centrilobular congestion and
Edema of Feet necrosis
VII. Bacterial Peritonitis
1. Cirrhosis ofliver
Signs of septicemia with ascites and a focus of
2. Constrictive pericarditis
infection (e.g. indwelling catheter).
3. Restrictive cardiomyopathy
VIII. Pancreatic Ascites
4. Hepatic venous occlusion
Intermittent abdominal pain with massive
5. Tuberculous peritonitis refractory ascites and increased serum amylase.
6. Intra-abdominal tumor IX. Congestive Cardiac Failure
Differential Diagnosis A. Starts with edema of feet, more in the
evening
I. Cirrhosis of Liver
B. Raised JVP
A. Signs ofliver cell failure
C. Tender hepatomegaly
B. Signs of portal hypertension
D. Heart size may be enlarged
C. Ascitic tap: Transudate
X. Nephrosis
II. Tuberculous Peritonitis A. Starts with puffiness of face, more in the
A. Fever with evening rise in temperature morning
B. Night sweats B. Pallor
C. Tender doughy abdomen C. Massive proteinuria
D. Ascitic tap: Exudate D. Hypercholesterolemia
E. Liver and spleen usually not palpable XI. Anemia, Hypoproteinemia
III. Malignant Peritonitis A. Gross anemia
A. Diffuse abdominal pain B. Edema out of proportion to ascites
B. Weight loss C. Serum proteins Albumin-globulin ratio
C. Hemorrhagic ascitic fluid with positive (A:G) reversed
malignant cells XII. Beriberi
IV. Portal Vein Thrombosis A. Cardiac enlargement and tachycardia
Sudden rapid development of ascites, melena, B. Tender calf muscles with blunting of
splenomegaly and hematemesis. sensations and absent deep reflexes
V. Constrictive Pericarditis XIII. Epidemic Dropsy
A. Pulsus paradoxus A. Family history of edema
B. Raised JVP on inspiration (Kussmaul's sign) B. Preceding or accompanying other gastro
C. Apex beat not palpable intestinal symptoms

71
PRACTICAL MEDICINE
C. Cardiac symptoms may be present 6.Consistency: Soft, firm or hard. Hard
D. Diffuse blotchy erythema of skin and other swellings are usually malignant, soft
cutaneous nodules swelling may be cystic.
E. Glaucoma 7. Mobility: This should be determined
by hand in all directions, i.e. from side
F. Detection of argemone oil in cooking
to side and above downward.
medium
8. Parietal or intra-abdominal: This
Management of Ascites can be found out by making the
I. Treatment of cause abdominal muscles taut by raising
the shoulders or the legs. If the
II. Diet: Low sodium diet
lump becomes less prominent it is
III.Diuretics: Spironolactone or furosemide or intra-abdominal. If it becomes more
combination prominent it is parietal. Ifmobile over
IV. Abdominal paracentesis if cardiorespiratory the contracted muscles it is superficial
embarrassment with or without albumin to the muscles and if it is fixed it is
V. TIPS (Transjugular intrahepatic portosystemic adherent to the muscle
shunt) 9. Hernial sites for expansile impulse on
VI. Porta venous shunts for refractory ascites coughing
10. Pulsations (if present): Expansile

6 > Abdominal Lum


(aortic) or transmitted (lump over
aorta). If lump is not adherent to
aorta, pulsations disappear when the
Physical Examination patient is in knee-chest position.
I. General C. Percussion:
Appearance: Anemic, jaundiced or emaciated. 1. For dullness of the tumor
Lymph nodes, especially supraclavicular. 2. Dullness over liver and spleen or
II. Local resonance over kidneys
A. Inspection: 3. Fluid thrill and shifting dullness
l. Skin overlaying present in ascites, absent in ovarian
tumor
2. Position, size, shape and surface
D. Auscultation: For rub (perisplenitis and
3. Movement on respiration
perihepatitis)
4. Hernial sites
5. Scrotum Differential Diagnosis
B. Palpation: Abdominal Quadiants : The differential diagnosis of
1. Local temperature abdominal lump can be made based on location of the
2. Tenderness lump in one of the abdominal quadrant.
3. Muscular rigidity The abdomen is divided into nine regions by
4. Confirming inspection findings four imaginary planes (two horizontal and two
regarding the lump vertical).
5. Margins: It must be determined Two horizontal planes are transpylonic and
whether it is possible to get all round transtubercular planes.
the lump or not, well defined or ill­ Transpyloric plane - It passes through the tips of
defined, notch present or absent the 9th costal cartilage anteriorly and through

72
j
{ 3 > Abdomen

the body of LI Vertebra near its lower body descent of the inflamed gallbladder,
posteriorly. which touches the examiner's fingers.
Transtubercular plane • It passes through the If a stone is present in the common
tubercles of the iliac crest and the body of LS bile duct there is a triad of intermittent
vertebra. colic, intermittent jaundice and fever
Two vertical lines are the right & left lateral with chills and rigors.
planes corresponding to the midclavicular line 4. Courvoisier's law: In a patient with
or either side. obstructive jaundice, a palpable gall
Right Hypochondriac Region
bladder is seldom due to gall stones.
This is because the gall bladder is
I. Swellings in the Abdominal Wall Cold usually shriveled & non distendable
Abscess in long standing gall stone disease.
1. Fluctuant swelling with no signs of Therefore, in a pt. with obstructive
inflammation jaundice, a palpable gall bladder
2. Swelling becomes prominent when the indicates malignancy of gall bladder
abdominal muscles contract or pancreas.
3. Irregularity in the affected rib or deformity Exceptions to courvoisiers law i.e.
of the spine. Obstructive jaundice with a palpable
II. Intra-Abdominal Swellings gall bladder due to gall stone occurs
A. Hepatic in
I. It moves with respiration but is not i. Double impaction ofthe stone (in
mobile sideways the bile duct & in the cystic duct)
2. The swelling is continuous with ii. Gall stones in the cystic duct
the liver dullness without a band of (Mirizzi's syndrome)
colonic resonance iii. Mucocele of gall bladder
B. Gall Bladder C. Sub-Phrenic Abscess
1. Oval smooth swelling, the size of an 1. Pain in the right hyp ochondria! region
egg referred to the shoulders
2. Moveswith respiration,can be moved
2. Diffuse tender swelling in the right
sideways but cannot be pushed down
hypochondrial region
into the loin (like kidney swelling)
3. Signs of septicemia: High fever
Chronic Cholecystitis and Cholelithiasis
with rigors, sweating and marked
I. Pain over the right rectus muscle tachycardia
radiating to the inferior angle of
4. Screening: Raisedand fixed diaphragm
scapula, aggravated after fatty meals.
with gas under it
Often the patient makes an attempt
to get relief by frequent belching 5. Features ofthecausativecondition e.g.
or vomiting but relief is seldom perforated peptic ulcer, liver abscess
complete. D. Stomach and Duodenum
2. Gall bladder may be palpable. I. Carcinoma of Pylorus:
3. Murphy's sign is positive: i.e. a. There is an irregular firm lump,
Tenderness under the right costal which moves on respiration
margin at the lateral border of the b. Patient is usually elderly and has
rectus muscle when the patient takes anorexia and weight loss
a deep breath. This occurs due to the

73
PRACTICAL MEDICINE

c. Barium meal would show filling F. Kidney Lump


defect
.
Generalfeatures
2. Sub-acute Perforation ofa Peptic Ulcer Reniform or kidney shaped mass
a. Localized, tender, inflammatory which moves with respiration
mass may be present with a central • It is better felt in the loin than
abscess anteriorly
b. History of peptic ulcer It is usually ballotable
c. Barium meal would reveal the • There is a band of colonic resonance
ulcer over the swelling
E. Hepatic Flexure of Colon I. Hydronephrosis
l. Tuberculosis (Hypertrophic variant) a. Cystic fluctuant swelling with
This usually causes a lump in the typical characteristics of a renal
right iliac fossa, which may be drawn lump
towards the right hypochondriac b. Pain in the loin if it is very large
region by fibrosis.
c. Hematuria
2. Carcinoma of Colon
d. IVP:Clubbingoftheminorcalyces
a. This commonly occurs in men and dilatation of the pelvis
above the age 40 years.
2. Pyonephrosis
b. There is alternate diarrhea and
a. All the features of
constipation.
hydronephrosis
c. The lump is irregular, firm and
b. Renal angle tenderness (i.e.
moves poorly on respiration.
angle between teh 12th sib &
d. Occult blood may be present in outer border of erector spinae).
stools.
C. Septicemia: Fever with rigors
e. Filling defect may be seen on and sweating. dry furred tongue,
barium enema. leucocytosis and positive blood
3. Intussusception culture
a. There is sudden intermittent d. Urine examination: Pus cells and
abdominal pain with vomiting. white cell casts present
b. Absolute constipation may be e. Cystoscopy: Red and swollen
replaced later by passage of blood ureteric orifice on the affected side
and mucus (red current jelly) per 3. Polycystic Kidneys
anum without fecal odour.
a. Bilateral renal swelling in a man
c. There may be curved, sausage with or without dragging pain in
shaped lump in the line of the the loin
colon with its concavity towards
b. Hematuria
the umbilicus. The lump may
harden under examining fingers C. Uremia

synchronously with an attack of d. Urine: Low specific gravity with


screaming. albumin and a few casts
d. Barium enema wouldshow typical e. IVP: Attenuated and elongated
pincer shaped ending ofthe radio­ (spider leg) calyces with terminal
opaque material. dubbing or cupping.

74
( 3 > Abdomen

4. Renal Stones B. Dragging pain, discomfort or pain after


a. · Fixed, dull aching pain in the renal food resembling peptic ulcer
angle radiating from loin to groin IL Stomach and Duodenum
aggravated by movements and A. Congenital Hypertrophic PyloricStenosis
relieved by rest l. Common in infants about 3 weeks
b. Tenderness in the renal angle old
c. Renal lump palpable only if 2. Projectile vomiting and wasting
associated hydronephrosis 3. Visible peristalsis of the stomach
d. Album in uria, pyuria and 4. Pylorus may be felt as a well defined
hematuria may be present cylindrical lump
5. Wilm's Tumor B. Carcinoma of Stomach: Refer Pg. 73
a. Commonly seen in boys below 5 III. Liver: Refer Pg. 73
years of age. IV. Subphrenic Abscess: Refer Pg. 73
b. Painless, huge enlargement V. Kidneys: Refer Pg. 74
of kidneys without hematuria
VI. Transverse Colon: Refer Pg. 74
(hematuria occurs later when the
tumor bursts into the renal pelvis) VII. Pancreas:
c. IVP: Filling defect in the renal Pseudopancreatic Cyst
pelvis or spider leg deformity of It is a collection of fluid in the lesser sac of the
the calyces. Plain X-ray abdomen peritoneal cavity, resulting from trauma or
often reveals the tumor inflammation.
6. Hypernephroma Features:
a. Common in adult males l. Smooth rounded fluctuant swelling
b. Painless lump in the abdomen 2. Barium meal and abdominal sonography
c. Painless hematuria will show the swelling to be posterior to
the stomach
d. Development of recent varicocele
VIII. Aorta (Aneurysm of the upper part of the
e. E v id e nee o f m e t as t a s i s:
abdominal aorta): Swelling in the epigastrium
Spontaneous fracture, hemoptysis
exhibits expansile pulsation. (It can be
f. IVP: Spider leg deformity of the differentiated from the transmitted pulsations
calyces, frequently distorted by by the knee elbow position).
the tumor. Complete absence of
excretion or scattered patches of Left Hypochondriac Region
dye in kidney areas. I. Parietal Swellings: Refer below.
7. Perinephric Abscess II. Spleen: Refer Pg. 67
a. Evidence of septicemia
b. Tenderness and rigidity in the Right and Left Lumbar Regions
renal angles. I. Parietal Swellings
c. Scoliosis of the lumbar spine with A. Umbilical Hernia
concavity towards the affected l. Common in fat multiparous women
side. above the age of 40 years
Epigastrium 2. Swelling situated just above the
I. Epigastric Hernia umbilicus where the two recti
A. Swelling in the midline in the parietal wall divaricate and thus allow the hernia
between xiphisternum and umbilicus to come out. Expansile impulse on

- 75
PRACTICAL MEDICINE
coughing and reducibility of swelling 4. Barium meal: Filling defect with
.is present spasm of the terminal ileum and
elevated position of the cecum
Desmoid Tumor of the Rectus Sheath
B. Carcinoma of the Cecum: Refer carcinoma
It is a fibroma that arises from a deeper part of the of colon, Refer Pg. 74
rectus abdominis muscle either spontaneously C. Amebic Typhlitis
or after an abdominal operation. The features
I. Irregular, firm, tender lump
are:
2. History of amebic dysentery
l. It is common is females
3. Stools will show E. histolytica
2. Firm rounded swelling which recurs after
operation (Recurrent growths become D. Impaction by Round Worms
more malignant than the original one) Irregular lump
II. Small Intestine and Mesentery IV. lliopsoas Sheath
Tuberculosis with Tabes Mesenterica A. Iliac Abscess
I. Irregular firm lump in sickly children and This results from infection of a hematoma in
young adults the traumatized iliacus muscle. It resembles
2. Subacute intestinal obstruction appendicular lump except:
3. Tuberculous lesions in thelungsand lymph I. The symptoms are all along over the
nodes iliac fossa and not shifted to this area
III. Retroperitoneal Sarcoma 2. A clear space is found between the
abscess and the iliac crest in case of
l. Young patient
an appendicular lump but not in an
2. Huge, firm, nodular mass attached to the iliac abscess
posterior abdominal wall
B. Cold Abscess from Pott's Disease
3. Edema offeet ifthere is pressure on inferior
I. Since it gravitates down deep to the
vena cava
inguinal ligament into the thigh,
IV. Stomach and Duodenum: Refer Pg. 73 fluctuation on either side of the
V. Colon: Refer Pg. 74 inguinal ligament is present.
Right Iliac Fossa 2. Gibbus of the spine clinically and
confirmed radiologically.
I. Parietal Swellings: Refer Pg. 75
V. Gall-Bladder
II. Appendkular Lump
A huge distended gall bladder with enlarged liver
I. Irregular, firm, tender lump initially fixed, may descends as low as the right iliac fossa.
slightly movable later and tympanic
VI. Unascended Kidneys
2. Leucocytosis
l. Swelling characteristically reniform
3. Signs of inflammation over the skin if the
2. IVP: Pelvocalyceal system in connection
abscess approaches the surface
with the swelling
III. lleocecal Region
VII. Undescended Testes
A. Hyperplastic Ileocecal Tuberculosis
When palpable, it is always pathological:
l. Irregular, firm, tender, intermittent
I. Hard, irregular, fixed lump if malignant
lump oflong duration
2. Caecum is pulled upwards 2. Absence of tests in scrotum
3. Tuberculous manifestations in lymph VIII.Uterus and the Appendages
nodes and lungs Swellings in connection with the uterus and

76
< 3) Abdomen
the appendages usually are associated with 2. Copious discharge of mucus per rectum
m enstrual disturbances. Vaginal examination and frequency of micturition.
will confirm the origin of the swelling in the 3. Rectal examination reveals bulging of the
right iliac fossa. anterior wall of the rectum.
Hypogastrium Left Iliac Fossa
I. Parietal Swellings: Refer Pg. 75 I. Parietal Swellings: (As above).
II. Urinary Bladder
II. Sigmoid Colon
l. Globular swelling in the hypogastrium
A. Carcinoma
which may extend from symphysis pubis
to the umbilicus 1. Increasing constipation
2. The lump is tender and dull on percussion 2. Loaded colon proximal to stenosis,
3. Pressure induces a desire for micturition pits on pressure
III. Uterus and its Appendages 3. Barium enema: Constant fillingdefect
Spherical midline swelling above symphysis B. Diverticulitis
pubis harder than urinary bladder (it should 1. Evidence of diverticulosis: Flatulent
be a rule to exclude swelling of the bladder by distension oflower abdomen, usually
passing a catheter before concluding that it is in patients over 40 years age
uterine swelling). 2. Evidence of inflammation: Pain and
IV. Fallopian Tube and Ovary tenderness in the left iliac fossa
A. Chronic Salpingitis 3. Barium enema: Saw tooth appearance
l. Attack ofpelvic peritonitis: Pain, fever of multiplediverticula with narrowing
and bladder disturbances of the colon
2. Mass in the midline or on one or other Ill. Iliopsoas Sheath: (As above)
side of the midline IV. Undescended Testes: (As above)
3. Vaginal examination confirms the V. Unascended Kidneys: (As above)
diagnosis
B. Ovarian Cyst or Tumor
1. Mass arising from one side of the 7 Acute Viral Hepatitis
pelvis but later on may become central
Etiology: Acute viral hepatitis can be caused by any
2. Menstruation normal or scanty one of the following:
3. Vaginal examination conf irms
1. Hepatitis A Virus: This is an RNA virus
attachment to the uterine appendages
4. Swelling has dullness over the front Capsid
of the abdomen with resonance in
the flanks (In ascites resonance in the ---l�- Initiation
center and dullness in the flanks) peptide

C. Ruptured Tubal Gestation


RNA­
1. History of missed periods dependant
2. A lump few days after the leakage polymerase ____,..._Singlo (+)
strand
V. Pelvic Abscess (it may follow acute appendic­ RNA
itis, salpingo-oophoritis and puerperal
sepsis)
Fig.3 20:Hepat1t1sAV1rus
1. Constitution symptoms
77
PRACTICAL MEDICINE

transmitted by feco oral route. Incubation with a rise in liver function tests. It usually has
period is 2-6 weeks. Usually it does not lead to a chronic severe clinical course.
chronic disease or carrier state. Acute infection 5. Hepatitis E Virus (formerly called enterically
is anicteric in 50% of patients. Usually seen in transmitted non-A non-B hepatitis) is an
children below 15 years age. RNA virus. It resembles Hepatitis A, is
2. Hepatitis B Virus: This is a DNA virus transmitted by feco-oral route and is found to
transmitted parenterally. The incubation period occur in endemic areas like India, Asia, Africa
is 2-25 weeks. About 10% of patients develop and Central America. It is seen to occur in
chronic disease or a carrier state. individuals who are immune to HAY infection.
Nudeocapsicl pro1cin Usually seen in adults and used to be wrongly
(soluhlo. non-p•tr1icuh1hi I rnnt\gl
labelled as 'A' in the past.
Surfoce<:oall 6. Hepatitis F, G and H viruses have been recently
llll!sAg)
described.
7. Other viruses: Epstein Barr virus, cytomegalo
virus, herpes simplex virus, rubella virus and
virus of yellow fever may all cause hepatitis.
'""_'--_,..:;,;.._,.,._ J11<:01nplc-tt?
t.lo1lhlc,slrandc-d
c:in:ular DNA Oinical Features
1. Influenza-like syndrome is common in hepatitis
A with malaise, anorexia and fatigue
F,g 3 21 Hepat,t,s BV,rus
2. Arthritis and urticaria is common with hepatitis
3. Hepatitis C Virus (formerly called non-A B and is probably due to circulating immune
non-B hepatitis) is a single stranded RNA virus complexes
transmitted parenterally. The incubation period 3. Jaundice with dark urine and light stool occur
varies from 2-25 weeks. About 20-30% develop in 50% of patients
chronic hepatitis, 50% of which is chronic active
4. Tender hepatomegaly is common and
hepatitis which would ultimately lead to cirrhosis
splenomegaly occurs in 20% of cases
of liver.
4. Hepatitis D Virus or Delta agent: This is a small Complications of Acute Viral Hepatitis
incomplete RNA virus which is infectious only 1. Fulminant hepatic failure
in presence of Hepatitis B surface antigen. It is 2. Relapsing hepatitis
thus a "superinfection" to hepatitis B infection 3. Cholestatic hepatitis
ora "co-infection" which occurs simultaneously
4. Post-hepatitis syndrome
Hepatitis B 5. Chronic hepatitis
Surface
antigen 6. Cirrhosis of liver
coat 7. Hepatocellular carcinoma
(HBsAg)
8. Aplastic anemia
Delta 9. Henoch Schonlein purpura
antigen
{protein)
10. Renal failure
11. Connective tissue disease
+--B- Single
stranded 12. Papular acrodermatitis
circular
RNA Diagnosis
I. To diagnose Viral Hepatitis
1 F,g.3 22:Hepat1t1sDV1rus!Deltaagent)
1. Typical clinical features

78
--
( 3) Abdomen

2. Elevated SGOT, SGPT, LDH, bilirubin and patients experience nausea in the evening. If
alkaline phosphatase there is persistent vomiting, intravenous fluids
II. To diagnose the type of hepatitis (Tables and must be given. Usually excessive fatty foods are
Figs. 3.8, 3.9 &3.10) not tolerated well and are hence avoided.
1. In Hepatitis A, anti-HAV IgM antibody is 3. Drugs: There are no specific drugs useful for
elevated early followed by anti-HAV IgG viral hepatitis. All hepatotoxic drugs as well as
in 2-3 months. alcohol must be withdrawn.
2. In Hepatitis B, HBsAg is positive. In acute 4. For post hepatitis syndrome: The patient requires
recent infection anti-HBeAb denotes reassurance.
marked infectivity. HBsAg +ve for >6 Table 3.5 : Diagnostic Approach in Acute
months indicates carrier state (See Table). Hepatitis
3. In Hepatitis C, anti-HCV may be positive, Diagnosis Anti- HBsAg Anti-
especially in chronic carriers. The most HAV lgM HBc/gM
sensitive indication is the presence ofHCV 1. Acute Hepatitis A +
RNA.
2. Acute Hepatitis B ±" +
4. In Hepatitis D, HDAg or rising anti-HD V
3. Chronic Hepatitis B +
antibody titre may be present.
5. In Hepatitis E, anti-HEV antibodies or 4. Acute Hepatitis A & B + ±" +
HEV RNA may be present. 5. Acute Hepatitis A on + +
Chronic Hepatitis B
Treatment
6. Acute Hepatitis C, Dor F"
1. Rest: Prolonged bed rest is not usually needed "HBsAg may be sometimes below detectable levels by the
but patients feel better with restricted activities. conventional tests, hence can be negative
2. Nutrition: A high calorie diet should be given. ..anti-HCV, HDAg, anti-HEV can be tested if all three
serological tests above are negative.
It is usually given in the morning because many

Table 3.4: Differentiating Features of Various Hepatitis


Hepatitis A HepotitisB Hepatitis( HepatitisD Hepotit1sE

1. Type ofvirus RNA DNA RNA Incomplete RNA RNA


2. Incubation period 15-45 days 30-tSOdays 15-150 days 30-lSOdays 15-60days
3. Age ofonset Usually pediatric All ages Adults All ages Young adult
age group< 15 yr
4. Transmission Feco-oral Percutaneous Percutaneous Percutaneous Feco-oral
Sexual Perinatal Blood borne Sexual Perinatal
5. Severity Mild Often severe Moderate Often severe Mild
6. Jaundice Common Common Uncommon Common Common
7. Progression to None 5-10% Approx.SO% < 10% coinfection None
Chronicity: 70%
superinfection
8. Carrier state None 0.1-30% 1% Variable None
9. Prophylaxis IG or vaccine HBIG or vaccine No vaccine Hepatitis B vaccine No vaccine
available available
10. Prognosis Good Worse with age Moderate Worse in chronic Good except in
and debility cases, good in pregnancy
acute cases

79
PRACTICAL MEDICINE

Table 3.6 : Interpretation of Serological Tests of Hepatitis B


HBsAg Anti-HBs Anti-H8c HBeAg Anti-HBe

1. Acute HBV infection lgM

2. Acute HBV infection with high infectivity + lgM +

3. Chronic HBV infection with high infectivity + lgG +


4. Chronic HBV infection with low infectivity + lgG +

5. Recovery from HBV infection + lgG ±


6. Remote past H BV Infection and low level HBsAg carrier lgG ±
7. Immunisation with HBsAg (after vaccination) or False positive or +
Remote past inf ection

8. HBsAg of one sub-type and hetero-type anti-HBs (common) + + + ;I;


seroconversion from HBsAg to anti-HBs (rare)

At.:r
Af:r
..........�..
:
�- 1
-.'-.- -
..\

t--t:=.i-
/
HB•A.,,_•·:-_-_-_-_-_-_-_-_-,:-
.I I HB•A ' HBV DNA
--
r:,H
I C'.".BV,:"'DN::--c,--,A--.
.....

Ii
1 11M anti-HBc I
a :---,
• ____ T�t •o.\1:HBrJ
-'!h-r,
� ,-=B::..:•.:..:
..-,- --
AJi.._' -�
. ____J
[_@eAs-- --­ ']
, '
.. •·.

-· '
' ··. '·-- --- .................... ��� ..................................
•,
- Time Fig. 3 25 · Reactivation of Chronic Hepatitis Bv1rus 1nfect1on
Time

hg 3.23 Acute Hepa1tt1s Bv,rus ,nfect1on


J preparations contain anti-HAY. It should

.-. .
be given within 2 weeks of contact in the

.
At.:r
''
',
, dose of 0.02 ml/kg_ For travelers a dose
'' ' 0.06 ml/kg should be given every 6 months.
: \. Hepatitis A vaccine is now available-
'/ .. -""'
c '-' -...-n-__' �--�
\>- HC\
b. Hepatitis B: A vaccine for active
'---.-------..,--.HCY
�R/IIA
=�
,/ '........ immunization has been prepared from
/ -----------------. HBsAg carrier serum as well as by genetic
Time engineering from recombinant yeast.
F,g 3 24.Acu!eHepat,t1sCV1rus:nfect1on
j
For pre-exposure prophylaxis, Hepatitis B
vaccine must be given at 0, l and 6-month
Prevention interval. The dose is 20 mcg LM. for
l. The patient should avoid salivary transmission immuno-compromised adults and 10 mcg
to others by avoiding kissing, spitting, sharing I.M. for infants and children under 10 years.
food, cigarettes or utensils and sexual contact. For post-exposure cases, a combination
Infected stools and urine in Hepatitis A and E of HBIG (for rapid achievement of high
infections must be disposed off carefully circulating titre of anti-HBs) and hepatitis
2. Immunization B vaccine (for long lasting immunity) is
a. Hepatitis A: All Immune globulin (JG) given.

80
( 3) Abdomen

For perinatal exposure of infantsofHBsAg arthritis of knee, ankle and wrist may occur
positive.mothers, HBIG 0 .5 ml should be along with vasculitis and glomerulonephritis.
given in thigh at birth followed by Hepatitis Prognosis is excellent as these rarely persist
B vaccine IO mcg started with a week of beyond 2 weeks.
birth and repeated at I and 6 months. 5. Hepatitis with aplastic anemia: This is rarely seen
For percutaneous exposure a single dose with acute viral hepatitis. The mortality rate is
of0 .06 ml/kg ofHBIG is given followed by high and no treatment has been effective.
three doses of hepatitis B vaccine.
Chronic Viral Hepatitis
Usually patients retain protective levels for
5 years after complete vaccination. Overview
c. HepatitisD: Thereis noimmunoprophylaxis
• Chronic hepatitis is a condition characterised
to prevent delta superinfection. Susceptible
persons are vaccinated with Hepatitis B by persistent liver inflammation for more than
vaccine. 6 months after initial exposure or diagnosis of
liver disease.
d. Hepatitis C and E: IG prophylaxis in this
hepatitis is not known to be beneficial and Cause of chronic hepatitis are : a) chronic viral
is not recommended. hepatitis (hep. B, Hep. C); b) Auto immune
hepatitis; c) Drug induced; d) Cryptogenic
Variants of Acute Viral Hepatitis (unknown cause).
Fulminant hepatitis: There is rapid onset of liver • Complications of chronic hepatitis include
I.
failure due to rapid liver cell necrosis which cirrhosis, portal HT, liver failure & HCC
occurs due to modification of host response to (hepatocellular carcinoma).
viral infection, allowing rapid viral replication Chronic Hepatitis B (CHBJ
Hepatitis B and C and superinfection with
• The risk of chronicity depends on the age &
delta agent accounts for majority of the
cases. Mortality in 3 weeks is 30% and 90- immune function when a person is infected.
100% above age 60 die. Clinically there is Infection at birth is associated with a 90%
progressive jaundice, hepatic encephalopathy chance of chronic infection while injection in
and hepatorenal syndrome prothrombin time young adulthood in immunocompetent person
is elevated. is associated with a risk of chronicity of only
approximately 1-5%.
2. Cholestatic hepatitis: There are features of
obstructive jaundice with alkaline phosphatase Symptoms of chronic hepatitis range from none,
elevated more than SGPT, during the course to non specific complaints (fatigue, Right upper
of viral hepatitis. It is to be differentiated from quadrant pain), to complication of cirrhosis.
biliary obstruction. The prognosis is excellent, • Extrahepatic manifestation, occur in up to 20%
recovery occurs over few months. of patients with CHB & include arthralgias,
3. Relapsing hepatitis: This occurs several weeks or PAN, glomerulonephritis mixed essential
months after apparent recovery. Sometimes it cryoglobulinemia, polymyalgia rheumatica
may be a second bout of hepatitis with a different and papular aero dermatitis (Gianotti Crosti
virus. Syndrome in children).
4. Viral hepatitis with autoimmune features: It Diagnosis
occurs in 5% of patients with Hepatitis B due
to circulating immune complexes. Serologic & Virologic tests
Anorexia, malaise, fatigue, urticaria, angioedema I. Diagnosis of HBV infection based largely on
migrating arthralgia and non-deforming detection of HBsAg

- 81
PRACTICAL MEDICINE

Table 3.7 : 4 phases of chronic HBV 5. CHB with elevated ALT levels & HBV DNA
insertion >2000 IU/ml.
: ..' iverbiapsy Treatment Treatment not indicated
l. Immune tolerance phase
1. Immune + N N or minimal No 2. Inactive carrier
tolerant inflammation
3. Acute hepatitis B
2. Immune + t Active Yes
active inflammation Drugs
(HBeAg+ve)
Current 1st line therapies
3. Reactivation + i Active Yes
(HBeAg-ve) inflammation 1. Pegylated interferon u- (exception : pregnancy,
decompensated cirrhosis)
4. Inactive + N Nor minimal No
carrier inflammation 2. Nudeoside analogs� Entecavir, Tenofovir
N• Normal Specific drugs
l. Pegylated interferon u: Consider in young, non
2. When HBsAg is detected, further laboratory cirrhotic pts. with low viral load and high ALT.
testing to assess disease status & need for
Treatment : 180 µg/wk s/c for 48 wks.
treatment is indicated.
2. Nucleoside analogues : High antiviral potency;
i. ALT levels
negligible adverse effects, oral administration,
ii. HBV DNA Quantitative (viral load) safe and effective for all ages, suitable for cirrhotic
iii. HBeAg & Anti HBe: To define the type of and HIV coinfected pts.
CHB & end point of therapy.
i. Lamivudine : 100 mg/day; high rate of
iv. Tests for liver disease activity • platelet resistance. ( specific point mutation YM DD
count, total bilirubin, albumin & PT/ INR motify of the HBV polymerase).
V. Liver biopsy � To determine histologic
ii. Adefovir dipivoxil: 10 mg/ day; potentially
grade & stage of disease.
nephrotoxic.
Treatment iii. Entecavir : 0.5 - 1 mg/day; low rate of
l. Goals of treatment resistance.
i. Prevention of long term complications iv. Tenfovir : 300 mg / day; low rate of
(cirrhosis, HCC) & mortality resistance. Adverse events: J. sed bone
density, Fanconi synd. (rare).
ii. Primary goal : sustained suppression of
HBVDNA. v. Others: a. Emtricitabine; b. Clevudine.
iii. Secondary goal: a)Decreasedornormalised Duration of Therapy
serum ALT; b) improved liver histology, c) l. HBeAg +ve: Treat until HBeAg seroconversion
HBeAg loss or seroconversion; d) HBsAg
and stop after consolidation, period 6-12 months
loss.
after HBeAg seroconversion.
Indications for HBV treatment 2. HBeAg · ve : Treat indefinitely because relapse
is common after stopping of therapy.
Treatment indicated

> Cirrhosis of Liver


l. Decompensated cirrhotic patients.
2. Any HBV DNA detectable in cirrhotic patients. 8
3. Fulminant liver failure
Definition
4. HBsAg +ve patients on immunosuppression
Cirrhosis of liver is chronic diffuse liver disease of

82
( 3 > Abdomen
varied etiology and characterized by hepatic cell in calories and carbohydrates may cause
necrosis, resulting in collapse, proliferation of connec, relative protein deficiency and contribute
tive tissue (fibrosis), nodular regeneration and altered to liver necrosis by infections and toxins.
intrahepatic circulation. b. Infections: Malaria, kala-azar anddysentery
cause malnutrition and contribute to
Classification cirrhosis. Schistosomiasis produces hepatic
1. Viral Hepatitis: Hepatitis B, C and D may lead fibrosis, which may progress to cirrhosis.
to cirrhosis of liver. c. Toxins: Aflatoxin-contaminated foodstuffs
2. Alcohol: An intake of about 80 gm of alcohol may produce cirrhosis. It is produced when
daily, for 15 years, may lead to cirrhosis. groundnuts, pulses or other nuts stored in
3. Prolonged cholestasis moist conditions get contaminated with a
4, Cardiac failure oflong duration induces fibrosis fungus • Aspergillus flavus.
around the central vein. d. Autoimmunity: Autoimmune antibodies
5. Drugs: INH-Isoniazid, methotrexate and as produced in SLE may lead to cirrhosis.
methyldopa may cause cirrhosis. e. Cryptogenic: The cause of cirrhosis is not
6. Congenital disorders: identified.
a. Hemachromatosis:Excessive ironabsorption Pathology
and deposition in the liver leads to cirrhosis.
0 ther features are diabetes, bronze colored The liver is firm, has a gritty feel on cutting and the
skin and myocarditis. cut surface shows fibrous bands surrounding nodules
of various sizes.
b. Wilson's disease: Excessive deposition of
copper leads to cirrhosis. Other features Microscopic examination would show necrosis, col­
are lenticular degeneration (involuntary lapse, fibrosis, regeneration and altered circulation.
movements, rigidity), greenish yellow ring Regenerating nodules, by compressing the blood
at the limbus of cornea (Kayser Fleischer supply of the liver cause ischemic damage of the liver
ring) and deficiency of ceruloplasmin. even after the disappearance of the primary cause of
c. Galactosemia: There is deficiency of the liver injury.
enzyme galactose-1-phosphate-uridyl Clinical Features
transferase. Galactose from milk is not
converted to glucose. Infants on milk diet Cirrhosis of liver may progress for years before any
may have malnutrition, diarrhea, jaundice, clinical suspicion is aroused because even 10% of
cataract and hepatosplenomegaly with healthy liver tissue is adequate for metabolic functions
cirrhosis of liver. and liver tissue has a remarkable capacity to regenerate.
The presenting features of cirrhosis are ascites, edema,
d. Alpha-1-antitrypsin deficiency: The normal
hematemesis or hepatic coma. The clinical features can
levels of this enzyme are 150-350 mg/L.
be classified as those due to liver cell failure and those
Levels less than 80 mg/Lmaycause cirrhosis
due to portal hypertension.
(mechanism unclear), pancreatitis and
recurrent lung infections with emphysema. I. Due to Liver cell failure:
7. Miscellaneous: 1. Palmar erythema, spider nevi
a. Nutrition: A diet low in proteins especially 2. Gynecomastia, testicular atrophy and loss
in methionine and choline may cause of libido
fatty liver and cirrhosis. A diet rich in 3. Jaundice - usually mild, may be severe
unsaturated fats (as in vegetable oils) terminally
may increase the susceptibility of liver 4. Ascites, edema and scrotal swelling
to cirrhosis. Similarly, a diet very rich 5. Flapping tremors

83
PRACTICAL MEDICINE

Table 3.8 : Differences between Biliary Treatment


and Portal Cirrhosis
l. Bed rest till improvement.
Biliary Cirrhosis Portal Cirrhosis
2. Diet: 2000 calories with about 100 gm proteins.
l. Sex Female Male Fats and carbohydrates as much as the patient
2. Pain and Pruritus Marked Uncommon tolerates. Salt is restricted if edema or ascites
3. Jaundice Marked Mild is present. Supplemental Vitamin B complex
should be given.
4. Splenomegaly Slight Marked
3. Diuretics: Spirono/actone is an aldosterone
5. Ascites Uncommon More common
antagonist that antagonizes the effects of
6. Hepatomegaly Marked Slight excess aldosterone present in cirrhotics due to
7. Clubbing Present Rare inadequate elimination of aldosterone by liver.
8. Xanthomas Maybe seen Absent 100 mg/day may be given. Maximum dose 400
mg . Frusemide can also be added up to 80mg.
9. Cholesterol Marked increase Normal or
diminished 4. Removal of cause: Withdrawal of alcohol,
lO. Alkaline Marked increase Slight increase D-penicillamine for Wilson's disease, etc.
phosphatase ornormal 5. Corticosteroids and immunosuppressants may be
helpful in active post-hepatitis cirrhosis.
6. Alopecia
7. Parotid swelling, Dupuytren's contracture 6. A ntifibrotic agents like colchicine and
propylthiouracil are still experimental.
8. Wasting
7. Interferon's utility is limited once cirrhosis sets in.
9. Chalky whitenails
It is useful only ifthere is actively replicating virus
II. Due to Portal Hypertension:
B or C and patient is awaiting transplant
l. Splenomegaly and hypersplenism
8. Transjugular Intrahepatic Porto-systemic shunts
2. Dilated veins over the chest wall (TIPS)
3. Hematemesis, melena and bleeding per
9. Artificial Liver Support
rectum
10. Hepatocyte transplant and ort hoptic liver
4. Ascites
transplant.
III. Liver is usually not palpable because it is
shrunken. However in a thin individual or with
alcoholic cirrhosis, it may be palpable with a
sharp edge and an irregular nodular surface.
9 Portal Hypertension
Definition : Portal Hypertension is defined by a
Complications pathologic increasse in portal pressure above the up­
1. Due to portal hypertension: Hematemesis, per limit of5 mm Hg.
thrombosis ofportal vein. Portal HT becomes clinically significant when the
2. Due to liver cell dysfunction: Hepatic portal pressure increases above the threshold value
encephalopathy. of 10 mm Hg (eg. formation ofvarices) or 12 mm Hg
(e.g variceal bleeding, ascites). Portal pressure values
3. Due to regenerating nodule: Hepatic
between 6 and 10 mm Hg represent subclinical portal
encephalopathy.
hypertension.
4. Due to ascites: Hernia
Portal HT is the most common & lethal complica
5. Due to associated infections: Tuberculosis, tion of chronic liver disease. [t is responsible for the
pneumonia and secondary bacterial peritonitis. development of gastroesophageal varices and portal
6. Hepatorenal syndrome hypertensive gastropathy, variceal hemorrhage, ascites,

84
{ 3) Abdomen

renal dysfunction, portosystemic encephalopathy, 2. IVC webs


hypersplenism & hepatopulmonary syndrome. 3. Cardiac causes - constrictive pericarditis,
Toe portal vein - systemic collateral circulation devel­ restrictive cardiomyopathy, severe CCF.
ops & expands in response to elevation of the portal
Clinical Features
pressure. The main sites of collatteral formation are :
1. Gastro-esophageal junction, 1. Splenomegaly
2. Rectum, 2. Hematemesis and melena
3. Retroperitoneum and 3. Ascites
4. Anterior abdominal wall via the umbilical vein 4. Encephalopathy
(caput medusae).
Treatment
Causes L Treatment ofcause: If the underlying cause can
J. Pre-hepatic: be identified, it should be treated.
1. Portal vein thrombosis II. Treatment ofVariceal bleeding:
2. Splenic venin thrombosis A. LocalNleasures
3. Massive splenomegaly (Banti's syndrome) L Sclerotherapy: Sclerosing agents like
4. A-V Fistula sodium tetradecyi sulphate and 3%
phenol in water are injected through
II. Hepatic: upper GI endoscopy, around the
1. Presinsuoidal - Schistosomiasis, Congenital varices. They obliterate the blood
hepatic firbosis, non cirrhotic, portal vessels and prevent future bleeds. It
fibrosis (NCPF) stops variceal bleed in 80% ofpatients
2. Sinusoidal - Cirrhosis, alcoholic hepatitis, and can be repeated ifbleeding recurs.
Wilson's, hemochromatosis However, if there is active bleeding,
3. Post Sinusoidal - Hepatic sinusoidal sclerotherapy is hazardous and first
obstruction (venoocclusive syndrome) the bleeding should be controlled by
primary biliary cirrhosis. balloon tamponade.
III. Post-hepatic: 2. Banding: This is a technique to
stop variceal bleeding in which the
1. Budd Chiari syndrome
varices are sucked into an endoscope
Table 3.9 : Differential Diagnosis
Cirrhosis of Liver Non-cirrhotic portal fibrosis EKtra-hepatic portal venous
(NCPF) obstruction (EHPVO)
1. Site of obstruction lntrahepatic, sinusoidal and lntrahepatic sinusoidal Extrahepatic
post sinusoidaI
2. G.l.bleeding Recurrent and frequent Infrequent Infrequent
3. Hepatic encephalopathy Common Rare (May follow shunt surgery) Rare
4. Ascites Common Rare Rare
5. Splenomegaly less than 5cm 10-20cm. 10-20cm.
6. Hepatomegaly Firm, irregular Fi rm, smooth Absent
7. Portal vein pressure High High Normal
8. Hepatic wedge pressure High High/Normal Normal
9. Liver biopsy Nodularity, loss of liver Phlebosclerosis, phlebo· Normal
architecture and fibrosis thrombosis with preserved liver
architecture

85
PRACTICAL MEDICINE

accessor y, allowing them to be to combat this. ECG monitoring is


ocduded with a tight rubber band. necessary.
The occluded vari subsequently 2. Somatostatin and Octreotide, a
sloughs with variceal obliteration. synthetic for m of somatostatin
However it is less easy to apply in is given in the dose of 50 mcg IV
acute bleeding. followed by an infusion of 50 mcg
3. Balloon tamponade: This is done with hourly. It is an expensive drug, but
Sengstaken-Blakemore tube which the drug of choice.
possesses two balloons and exerts 3. Terlipressin: It is not an active drug,
pressure in the lower esophagus and but vasopressin is released from it in
fundus of the stomach. The tube is sufficient amounts to reduce portal
passed through the mouth and its pressure without producing systemic
presence in the stomach is checked by side effects. It is given in the dose of
auscultating over the upper abdomen 2 mg IV every 6 hours until bleeding
while injecting air into the stomach. stops and then 1 mg IV for further 24
Gentle traction is used to maintain hours.
pressure on the varices. Initially only C. Prophylaxis
the gastric balloon is inflated, which
In patients with variceal bleed, recurrent
would control the bleeding. If the
bleeding is very common. This could be
esophageal balloon is also inflated,
prevented byregularsclerotherapy, banding
it is important to deflate it for l 0
or drugs like beta-blockers or nitrates.
mins every three hours to prevent
Propranolol 80-160 mg/day reduces portal
esophageal mucosa! damage. This
venous pressure and can be used to prevent
usually stops the variceal bleed, but
recurrent variceal bleed. Beta-blockers
only allows for time for more definite
are now routinely used in prophylaxis.
therapy.
However, they carry a theoretical risk of
4. Shunt surgery: Portocaval shunts increasing the hepatic blood flow and
also give excellent results with low thus hepatic encephalopathy. Nitrates are
morbidity and mortality and is a one second lineagents used in patients who are
time procedure unlike sclerotherapy intolerance to beta blockers.
which may have to be repeated.
D. TIPS (Transjugular Intrahepatic Portal
However, the incidence of hepatic
Shunt) used for patients awaiting liver
encephalopathy is high and death
transplant.
could result from liver failure. Hence
it is only used when other measures E. Liver Transplant
fail and offered only to patients with III. Treatment of Enlarged Spleen:
good liver functions. Massive splenomegaly, hypersplenism and
B. Drugs: Splanchnic flow can be reduced by splenic infarction may require splenectomy and
vasopressin, somatostatin (octreotide) and shunt surgery.
terlipressin. IV. Treatment of Ascites:
1. Vasopressin: ltisgivenasanIVinfusion, Salt restricted diet with diuretics spironolactone
0.4 units per min. until bleeding stops and of furosemide.
or for 24 hours and then 0.2 units per Massive ascites requires therapeutic tapping.
min. for a further 24 hours. It can
cause angina, myocardial infarction Autoimmune liver disease
and arrhythmias . Nitroglycerine • Autoimmune hepatitis is a chronic hepatitis
transdermally or IV should be used

86
{3 > Abdomen

C
3% per year
2_20% Hepatic clecotnpcnsr,t1on
5 5-•l0% over 20 years
Acute HCV infection -·-· -+ chronic HCV infection----� Cirrhosis

Hepatic carcinoma
1-4 'Y., per year
Frg.3 26·HCVJnfect1on

characterized by immune & autoimmune enhance treatment response and minimise the emer­
features. gence of viral resistance.
• Characterised by presence of circulating hyper
gammoglobulinemia and auto antibodies with
Wilson's Disease
interface hepatitis on liver biopsy. • Wilson disease is a genetic disorders (autosomal
• Treatment in with anti-inflammatory / recessive) in which copper accumulates in the
immunosuppressive therapy e.g. steroids and liver & brain is excess of normal metabolic needs.
Azathioprine. • Diagnosis: i) Low levels ofserum cerruloplasmin
• Liver transplantation in patients who do not i.e. less than 20 mg/ di (Normal: 20-50 mg/ di);
respond to medical therapy. ii) Hepatic copper concentration above 250 µg
/ g. dry copper wt.; iii) clinical findings include
Chronic Heaptitis C presence of kayser fleischer rings, stigmata of
HCV infection is a leading cause of morbidity chronic liver disease & neurologic findings.
and mortality with a global prevalence of 3%.
Treatment is life long
Natural history
i. Chelating agents eg. D-penicillamine, Trientene
Diagnosis
ii. Zinc salts
I. Detectable anti - HCV indicate exposure but
iii. Liver transplantation for acute liver failure or
does not confirm active infection, because anti·
decompensate liver disease.
HCV persistent indefintely after spontaneous or
therapeutic resolution
2. HCV RNA viral load should be performed in
all patients with positive anti-HCV assay & in
10 > Alcoholic Liver Disease
patients in whom antivrial treament is being (ALO)
considered. Alcohol induced liver injury results from chronic
3. HCV genotype - 6 major genotypes (I to 6) alcoholic ingestion which may be classified as :
Treatment I. Alcoholic fatty liver (AF)
l. Standard therapy consists of combination of 2. Alcoholic hepatitis (AH)
pegylated interferon (PEG IFN) and Ribavarin 3. Alcoholic cirrhosis ofliver (AC)
2. Sustained virolgical response (SVR) i.e. HCV Alcohol dehydrogenase (ADH) Acetaldehyde Dehy­
RNA negative 24 weeks after end of treatment drogenese (ALDH) Co2 Alcohol Acetaldehyde + H2o
is achieved in 45-80% of patients depending on Oriental flush syndrome : Results from impaired
the genotype. metabolism of acetaldehyde caused by inheritance of
Future the ALDH22 allele seen mainly in persosn from East
Asia (eg. Japan) causing toxic systemic effects such
Protease inhibitors such as Boceprevir and Telaprevir as nausea, headache, flushing & tachycardia of acet­
and Polymerase inhibitors such as safosuvir combined aldehyde accumulation. Therefore, tense patients get
with Ribavarin with or without PEG IFN will further symptom ofexcessive flushing after consuming alcohol.

87
PRACTICAL MEDICINE

hnmunc systcm !Oxidative, 1 Alcoholic Fatty Liver (AF}


j Ci,1,ilin.,� slross

r- i\Lr.OHOLHEPATrTrs
AF occurs in most heavy drinker but is reversible on

l l'
..
cessation of alcohol consumption.
Iron / 1
V1r;1I Pathology: The liver is enlarged, greasy, yellow and
Malnulrilion -c:..ni�le
Diel i\lcohol Gender
firm. Hepatocytes are distended with fatty vacuoles
which push the nucleus to the periphery. This occurs
Fig. 3 27 Risk factors/ cofactors required fort he because fatty acid oxidation is impaired and they are
developmentofadvancedALD
taken up by the cells and esterified to form triglycerides.

l
Normal Liver
Clinical features: The clinical features are minimum
or absent. There may be tender hepatomegaly only.
(!l0-100%J
Investigations: Usually all laboratory tests are normal.
Sometimes there may be elevation ofSGOT and alka
.------ Fatly Liver ----
line phosphatase.
Alcoholic: hepalilis -------+ Cirrhosis Prognosis: AF has good prognosis. Complete resolu­
tion occurs after cessation of alcohol intake.
Fig 3 28 Percentageofheavydrinkerswhodevelop
d1fferentstagesof ALD Treatment: Alcohol intake must be stopped. Nutri­
tious diet with high doses of vitamin B complex must
Risk factors of ALD be given.
1. Quantity : Risk of developing cirrhosis with Alcoholic Hepatitis (AH)
ingestion of>60-80 g / day of alcohol in men & AH is an inflammatory lesion characterized by infil­
>20 g/day in women for 10 years or longer. tration of the liver with leucocytes, liver cell necrosis
2. Gender : Increased susceptibility to ALD at and alcoholic hyaline deposition.
amounts> 20 g/day (2 units) [ l unit= 10 gm]. Pathology: Liver cells are ballooned, degenerated
3. Hepatitis C : Concurrent HCV infection and necrosed with infiltration with polymorphs and
associated with younger age for severity, more lymphocytes. Hepatocytes contain Mallory bodies or
advanced histology and decreased survival. alcoholic hyaline which are clumps of perinuclear,
deeplyeosinophilic material that represents intermedi­
4. Genetics: Gene polymorphisms include alcohol
ate filaments. Mallory bodies are not diagnostic but do
dehydrogenase (ADH) and the cytochrome P450
usually suggest alcoholic hepatitis. They are also seen
system (CYP4502El).
with morbid obesity, jejuno-ileal shunt, uncontrolled
S. Malnutrition : Nutritional status important risk diabetes mellitus, Wilson's disease, Indian childhood
factor for the development of ALD & diet. cirrhosis, etc.
Pathogenesis Clinical Features: This varies from asymptomatic
patient to mild illness to fatal liver cell failure.
The mechanism whereby alcohol produces different Typically it resembles Viral hepatitis
liver lesions is poorly understood. Fatty change may 1. Anorexia, nausea, vomiting, abdominal pain,
be due to increased production and decreased use of malaise, weight loss and jaundice
fatty acids in the liver cells following the conversion 2. Fever as high as 39 · 40 q C may be seen in SO%
of alcohol to acetaldehyde by alcohol dehydrogenase.
of cases
For the development ofalcoholic hepatitis, fibrosis and
3. Tender hepatomegaly is usually present.
cirrhosis, production of toxic metabolites called ad­
Splenomegaly occurs in 33% cases
ducts during the conversion of acetaldehyde to acetate
4. Signs of liver cell failure like spider angioma,
may be responsible. In addition, immune reaction to
jaundice, ascites, edema, GI bleeding and
liver cells altered by alcohol may also be involved.
encephalopathy may be present
Determinants of liver injury are :
5. Cholestatic jaundice may occur in some

88
( 3 > Abdomen
Most of the patient recover after several weeks to Prognosis
months after abstinence, however, histological ab­
normalities may persist for 6 months. 3 models shown to predict short term prognostic
in Alcoholic hepatitis.
Investigations l. Discriminantfunction (DF) (Maddrey's score):
1. Anemia may occur from GI bleeding, nutritional [ 4.6 x (patients prothrombin time - control
deficiency (folate and B12 deficiency), hyper­ value in seconds)]+ S. bilibrubin (mg/di). DF
splenism, direct bone marrow suppressant effect value<'. 32 has a poor prognosis with 1 month
ofalcohol and hemolysis due to acanthocytosis. mortality rates of 35-45%.
2. Leucocytosis is usually present. However, 2. Mode/for End Stage Liver Disease (MELD): It
leucopenia and thrombocytopenia could occur includes S. bilirubin level, INR & S. Creatinine
due to hypersplenism. levels. A score of<'. 21 is highly predictive of
90 day mortality.
3. Alkaline phosphatase may be elevated.
3. Glassgow Alcoholic Hepatitis Scale (GAHS)
4. SGOT is high but rarely more than 300 units.
: It includes S. bilirubin, INR, BUN, Age &
Unlike in viral hepatitis where SGPT is higher
WBC count. A score of <'. 9 at days l & 7 is
compared to SGOT, in alcoholic hepatitis SGOT
suggestive of severe alcoholic hepatitis & a
is much higher than SGPT. This is because of
poor prognosis.
greater inhibition of SG PT synthesis by ethanol
which may be partially reversed by pyridoxal Alcoholic Cirrhosis of Liver (AC)
phosphate.
AC is diffuse fine scaring with loss of liver cells and
5. Serum prothrombin is prolonged due to reduced small regenerating nodules (micronodular)
synthesis of Vitamin K dependent dotting
Pathology: With continued alcohol intake, liver cells
factors.
are destroyed and fibroblasts appear at the site of
6. Serum albumin is usually reduced due to injury and stimulate collagen formation. Septae of
impairment in hepatic protein synthesis. Globulins connective tissue appear in the periportal and peri­
are high due to non-specific stimulation of central zones which eventually connects portal triad
reticuloendothelial system. Hyperbilirubinemia and central vein. The remaining liver cells which are
may be present, due to decompensation. surrounded by connective tissue, regenerate and form
7. Hypomagnesemia and hyp ophosphatemia may nodules. Usually, cell loss exceeds regeneration. The
occur due to dietary deficiency. Hypokalemia may liver shrinks and becomes hard and nodular
occur due to hyperaldosteronism (aldosterone Alcoholic hepatitis

8.
is normally destroyed in liver).
Gamma Glutamyl Transpeptidase (GGPT) is
!
Alcohol abstinence
raised due to alcoholic abuse irrespective ofliver Nutritional support
disease due to microsomal enzyme induction.
Discriminant function i!: 32
Prognosis or MELD i!: 21
In milder cases, clinical recovery can occur completely. !
However, repeated bouts ofalcoholic hepatitis may lead GI bleed. acli ve infection, hepatorenal syndrome
to irreversible progressive liver injury, abstinence from No I Yes
alcohol can reduce long term morbidity and mortality. !
Prednisolone
l
Pentoxyfylline
Marked hyperbilirubinemia, elevated creatinine, 40 mg p.o. daily x 4 weeks 400 mg lid x 4 weeks
elevated prothrombin time (more than 1-5 times followed by 20 mg daily x 1 week
normal), ascites and encephalopathy are associated & 10 mg daily x 1 week
with poor short term prognosis. F,g 3 29 T,e,)tment /\l9or1thn1 fo1 /\lcohof1c 11eµ<1l1l1s

89
PRACTICAL MEDICINE

Clinical Features: It is usually silent in 10% of cases. form schizonts but develop into male and female gam­
The clinical manifestations are like cirrhosis of liver. etes. During the mosquito bite, these gametocytes are
Dupuytren's contracturedue to fibrosis of palmar fascia ingested. They fertilize in the mosquito's stomach and
with resulting flexion contracture of the digits and develop into sporozoites which localize in the salivary
parotid swelling are associated with alcoholism rather glands of the mosquito. These sporozoites enter the
than cirrhosis. human blood stream on a subsequent mosquito bite
and thus complete the cycle.
Laboratory Tests: Similar to alcoholic hepatitis. El
evated blood ammonia may also occur due to impaired Clinical Features
liver function and shunting of portal venous blood
around the cirrhotic liver. 1. Onset: The onset may be insidious with
abdominal pain, nausea, dry cough and malaise.
Prognosis: Similar to alcoholic hepatitis
Rarely it may be acute and with fever and chills.
Treatment: Similar to cirrhosis of liver 2. Fever with rigors: In the early stage, fever may
be persistent for several days but soon it develops

11 > Malaria
into a synchronous periodicity. A classical attack
offever has a chill, rise in temperature to 40-41 °C,
Malaria is a common tropical disease caused by a headache and myalgia. This is followed by several
protozoa, plasmodium, through the bite of female hours of profuse sweating and fall in temperature.
anopheles mosquito. In vivax and oval malaria these paroxysms occur
every 48 hours (benign tertian) whereas in
Types malaria, it occurs every 72 hours (quartan). In
falciparum malaria, the temperature is usually
There are mainly four types of plasmodium infection
causing malaria as follows: persistently elevated or may progress to 48 hour
cycle (malignant tertian malaria). These cycles
I. Plasmodium falciparum (Malignant tertian may be repeated in case of benign tertian malaria
malaria) due to exo-erythrocytic phase.
2. Plasmodium vivax (Benign tertian malaria) 3. Organomegaly: Liver is moderately enlarged and
3. Plasmodium malariae (Quartan malaria) tender. Spleen is often palpable in acute attack. It
4. Plasmodium ovate is soft to firm and occasionally tender.
4. Miscellaneous: Herpes simplex lesions may be
Life Cycle (Fig. 3.30)
present around the mouth. Rarely jaundice may
When an infected mosquito bites an individual, its occur.
saliva, rich in parasites (sporozoites) is injected. The
sporozoites enter he circulation and then the liver Investigations
(pre-erythrocytic phase). It multiplies in the liver 1. Complete Blood Count and Demonstration of
cells forming merozoites. After 5-9 days, the mero parasites: There is normochromic normocytic
zoites enter the red blood cells (erythrocytic phase) anemia. Both thick and thin smears should be
forming trophozoites which subsequently mature to examined for detection and identification of the
become schizonts. The schizonts are discharged int.o malarial parasites. Blood smears must be repeated
the blood stream when the red cells degenerate. This at intervals of 6 12 hours on multiple occasions.
results in an attack of malarial fever. The red cells are Malarial parasites can also be demonstrated
destroyed by the spleen which enlarges and some of on bone marrow examination and by splenic
the schizonts continue to develop in the liver (exo­ puncture.
erythrocytic phase) causing a relapse. This phase is Criteria for severefalciparum malaria:
absent in falciparum malaria.
a. More than 5% of RBCs infected
Some of the merozoites for unknown reasons do not
b. Parasites index more than 1,00,000/ul

90
( 3 > Abdomen
c. More than 250 parasites per field on thick b. Leucocytes are usually normal. However,
smear leucocytosis without infection may occur
d. Leucocytosis due to cachectin (tumour necrosis factor)
2. Serology: Henry's melanin flocculation test, and carries grave prognosis.
complement fixation test, passive hemaglutina­ c. Thrombocytopeniamay bedue to decreased
tion test, gel precipitation test and immuno­ platelet production, decreased platelet
fluorescent technique to demonstrate antibodies survival, increased splenic uptake and
to malarial parasite are useful. sequestration and consumption by DIC.
3. Otherinvestigations: Serum electrolytes, BUN, d. Bleeding may occur due to DIC.
creatinine, blood sugar, ECG, chest X-ray, arterial 4. Renal failure: (defined as urine output
blood gases, blood culture, lumbar puncture if <400ml/24 hours and failure to improve after
necessary. rehydration). The patient may present with loin
4. Newer Methods: Polymerase Chain Reaction pain, vomiting, diarrhea, polyuria followed by
(PCR) and serological tests based on histidine oliguria with passage of dark or black urine, with
rich protein 2 (HRP-2) (e.g. Parasite F and ICT or without fever, tender hepato-splenomegaly,
Ff) and pLDH (e.g. Optimal). anemia, jaundice, hypotension, renal failure and
Complications coma. Acute glomerulonephritis and nephrotic
syndrome may also occur. lntravascular
1. Cerebral malaria: This is an altered state hemolysis, hypovolemia, hyperviscosity and
of consciousness due to the presence of Pl.
intravascular coagulation may be responsible
falciparum. Patient usually has fever and non­
for renal failure.
specific symptoms for a few days before the
development of cerebral malaria. There may be Blackwater fever is a condition where renal
mild neck rigidity and retinal hemorrhages but no failure is associated with severe intravascular
white exudates or papilledema. Deep reflexes are hemolysis and hemoglobinuria. If the patient
brisk and plantarsextensor with absent abdominal survives acute phase, urination commences in
reflexes. Psychiatric manifestations, convulsions 4 days and increased creatinine levels return to
and coma may occur. Rarely brainstem may be normal in 3-4 weeks.
involved, manifested by convergence spasm, 5. Pulmonary edema: This occurs due to
ocular bobbing and nystagmus. Cerebellar Table 3. 1 O : Complications of
ataxia, may occur. Rare manifestations are Plasmodium Infections
cranial nerve palsy, extrapyramidal syndromes,
Plasmodium falciparum
polyneuropathy, mononeuritis multiplex, Guillain
Barre-syndrome and rhabdomyolysis. Cerebral malaria including seizures and coma

2. Algid malaria (shock): There may be subnormal Hypoglycemia, lactic acidosis


temperature, weakness, prostration, feeling of Severe anemia
cold, vomiting, rapid respiration and oliguria. Pulmonary edema
Death may occur but the patient is conscious
• Tropical splenomegaly (chronic)
till the end. It could be due to adrenal crisis,
absorption of endotoxin from gut or cachectin­ • Blackwater fever
tumour necrosis factor from endotoxin activated Plasmodium vivax
macrophages. , Late splenic rupture (2-3 months after initial infection)
3. Hematological abnormalities: Plasmodlum malarlae
a. Normochromic anemia may occur due
Immune complex glomerulonephritis (with parasite
to hemolysis, inappropriate bone marrow antigen, host lgG and complement)
response and increased sequestration and
Nephrotic syndrome
destruction in the spleen.

91
PRACTICAL MEDICINE

In Mosquito InMan
Seorozoices
inj�bv
mosquito bite

��------Sporozoitcs

'� Pre-erythrocytic cycle


Fig 3.ll :Plasmod1um\��a�:R,n9formof
trophozoJt�
��

·.o.· Fig. 3.32: Plasmod1um v,vax Sch,zont


:ii
reproducrion

F,g 3.33 Plasmod,um falc,parum


F,g 3.30: life cycle of malaria banana shaped gametocyte

Table 3.11 : Characteristics of Plasmodium Species Infecting Humans


Characteristic P. Falciparum P. vivax P. ovate P. molariae

1. Duration of intrahepatic 5-7 7-8 9 14·16


phase (days)
2. Duration of erythrocytic 48 48 50 72
cycle (hours)
3. Red cell preference Younger cells but can Reticulocytes Reticulocytes Older cells
invade cells of all ages
4. Morphology Usually only ring forms; Irregularly shaped large Infected erythrocytes Band or
parasitemia level may rings and trophozoites; enlarged and oval; rectangular forms
exceed 2%, with multiple enlarged erythrocytes; Schufner's dots oftrophozoites
infections of a single Schufner's dots common; no RBC
erythrocyte;occ. banana enlargement; no
shaped gametocyte Schuffner's dots
5. Pigment color Black Yellow-brown Dark brown Brown-black
6. Relapses No Yes Yes No

92
( 3 > Abdomen

RED CELL
MORPHOLOGY TROPHOZOITE SCHIZONT GAMETOCYTE
AND GENERAL (RING FORM)
FEATURES
Very enlarged red cells

..0..
Pale, fine red stippling
(Schuffner's dots]

'>
;.., Low or moderate para­
sitemia
Thick compact rings > 1/3
12-24 medium-sized
merozoites per cell: Large and round or oval,
� All stages of life cycle size of RBC with single almost fill the cell almost fills the cell
present Red central or eccentric
large chromatic dot. 1 Schuffner's dots present.
Multiple parasites per Few Schuffners dots. single nucleus
, 1-2 clumps of peripheral
cell may be present yellow-brown Fine scattered pigment
Ameboid ring forms in
mature trophozoites. fine hemozoin pigment.

Normal sized red cells,


normochromic Schizont not usually
Maurer's clefts or dots seen in peripheral
may be present blood.
Heavy parasitemia (except occassionally
Delicate rings< 1/3 size in cerebral malaria) Crescent or banana­
Sometimes multiple ofRBC. shaped, deforms the cell
parasites per cell often If present, 8-24 very
Double chromatic dots small merozoites, which may appear pale
at margins and empty.
per ring common. grouped irregularly
Often only ring forms and filling 2/3 of red Diffuse chromatin, cen­
Small chromatin dot
present cell. tral single nucleus
No Schuffner's dots.

...
- .o.-:
Enlarged red cells, some

. .. . .
oval shaped, some with
fimbriated edges
Pale, fine to coarse red
stippling (Schuffner's
dots) Oval shaped, fills 3/4 of
Low parasitemia Thick compact rings 8-12 large merozoites the cell. Smaller than
> 1/3 size of RBC . per cell. vivax.
Multiple parasites rare
Single chromatic dot Daisy-head arrangement Coarse brown pigment,
Fewer stages present Schuffner's dots present. scattered mainly near
Numerous Schuffner's
dots. Central brown pigment. periphery.
r
Normal or microcytic,
normochromic red cells
Lowest parasitemia
Multiple parasites per
cell rarely found Small, thick compact
No stippling rings< 1/3 size of RBC.
All stages usually present Single chromatic dot, 6 ·12 large merozoites Round, fills 1/2 to 2/3
double dots rare. per cell. of the cell.
Ameboid rings or band Daisy-head arrangement Prominent brown black
across cells in mature Central coarse dark pigment.
trophozoites. brown pigment. Dark nucleus.

Fig. 3.34: Features of Malarial Parasites in Peripheral Blood

-
93
PRACTICAL MEDICINE

increased capillary permeability due to effects 8. Trypanosomiasis


of endotoxins and cytokines. Hyperparasitemia, 9. Hemorrhagic fever
renal failure and pregnancy are predisposing
factors. It occurs suddenly after 1-2 days of Treatment
starting treatment with increased respiratory I. Supportive Measures
rate, breathlessness, hemoptysis and collapse. 1. Fluid deficit assessment and correction
It carries high mortality.
2. Fever control
6. Lactic acidosis: Parasitized red cells interfere
3. Convulsion treatment
with micro circulatory flow leading to anaerobic
glycolysis in tissues. This with hypotension and n. Specific Treatment
inadequate hepatic lactate clearance causes A. Treatment of Chloroquine-susceptible
lactic acidosis, which is characterized by P. vivax, P. falciparum, P. ovale, P. malariae
hyperventilation and circulatory failure resistant Chloroquine: This is given in the dose of
to volume expansion and inotropic agents. 600 mg (base) followed by 300 mg at 6, 24
Prognosis is very poor. and 48 hours. (In children IO mg/kg of base
7. Gastrointestin al: Nausea, vomiting and as loading dose and 5 mg/kg subsequently).
diarrhea with or without blood and pus may This is useful to treat acute attack of all types
occur. Endotoxin that is absorbed from the gut of malaria. It is curative for PI. falciparum
results in cyto adherence of parasitized red cells malaria, but cannot prevent relapses due to
in the blood vessels of villi leading to ischemic exo-erythrocytic cycles of Pl. vivax malaria.
damage of the epithelium. There may be failure It can be given intravenously 600 mg diluted
of normal hepatic clearance mechanism. Rarely and given slowly followed by 900 mg over
pancreatitis occurs. the next 24 hours.
8. Hypoglycemia: This occurs due to quinine and Drug resistance: In vivo, the response to
quinidine, which stimulates pancreatic insulin chloroquine treatment, given as 1.5 g base
secretion. There is also increase in glucose or 2.5 g salt over 3 days, is graded as below:
consumption by host and parasite, glycogen S: Susceptible (Produces a cure)
depletion and decreased gluconeogenesis. RI: Low-level resistance (clearance of parasitemia
Pregnancy predisposes to hypoglycemia. followed by recrudescence within 28 days)
9. Other infections: Malaria has immuno­ RH: Intermediate-level resistance (Decrease in parasitemia
depressant action resulting in high incidence with parasite cleara nee from blood)
of infectious diseases. RIii: High-level resistance (No detectable decrease or an
10. Other complications: Prostration, jaundice, increase in parasitemia)
orthostatic hypotension, aspiration pneumonia. B. Treatment of Chloroquine-Resistant P.
falciparum
Differential Diagnosis of Severe
Falciparum Malaria 1. Quinidine is preferable to quinine
for parenteral use. It is given IV,
1. Meningitis (bacterial, viral, protozoa!, fungal) the loading dose being lOmg/kg
2. Viral encephalitis (measles, Japanese B, rabies) dissolved in 300 ml normal saline
3. Enteric fever infused over 1-2 hours. This is
4. Septicemia, puerperal sepsis followed by constant infusion at 0.02
mg/kg/min till oral therapy with
5. Severe or fulminant hepatitis quinine can be given.
6. Leptospirosis 2. Quinine hydrochloride: 600 mg tds
7. Relapsing fever for 3-7 days is useful. This drug can
be given intravenously if required for

94
( 3 > Abdomen
cerebral malaria. The dose is 7 mg/kg D. Treatment of Persistent Hypnozoites in
over 30 min followed by 10 mg/kg P.vivax or P. ovale Infections
over 4 hours and then 10 mg/kg over 8 1. Primaquine: This should be given
hours or until the patient can complete in the dose of7.5 mg BD for 14 days
7 days of oral treatment. Doxycycline usually after doing a G6PD test. This
should also be simultaneously given has no effect on acute attack.
in the dose of 100-200 mg/day.
2. Bulaquine is given 25 mg OD for 5
3. Mefloquine: I t has a rapid days.
schizonticidal action in the single
III. Treatment of Complications
dose of 15 mg/kg orally maximum
dose 1000-1250 mg. It may cause IV. Prophylaxis
nausea, vertigo, light-headedness, 1. Measures should be taken to prevent
confusion, psychosis and fits. mosquito breeding e.g. proper sewage
4. Halofantrine: This is effective in some drainage, and preventing stagnation of
parts of Africa against P. falciparum. water. Spreading oil over the water helps
It is given in the dose of 500 mg every to kill the larva.
6 hours for 3 doses. [n children the 2. Protective measures should be taken by
dose is 8 mg/kg. persons staying in endemic areas. This
5. Qinghaosu: This is discovered from includes sleeping under mosquito net and
herbs by Chinese and is effective wearing protective clothing.
for P. falciparum. Artemisinin 3. Travelers to endemic areas must take
derivatives are rapidly acting, safe and prophylaxis as given in Table below.
effective against multi-drug resistant
Table 3.12 : Malaria Prophylaxis for
infections. Artemether 3.2 mg/kg IM
Travelers
is given followed by 1.6 mg/kg [M
every 12-24 hours until patient wakes Areas with Chloroquine-susceptible P. falciparum
up. Chloroquine 300 mg of base once weekly for 1 week before
exposure, during exposure and for 4 weeks after exposure..
Artesunate 2 mg/kg I. V. stat followed
Areas with Chloroquine-resistant P. falciparum
by I mg/kg 12 hourly. Mefloquine 250 mg of base once weekly for 1 week before
Orally - 100 mg B.D. Day I followed exposure, during exposure and for 4 weeks after exposure
by 50 mg B.D. Days 2-5. or
Chlorguanide (Proguanil) 300 mg daily for 1-2 days before
6. Pyrimethamine and sul fadoxime: exposure, during exposure and for 4 weeks after exposure
A combination of pyrimethamine 25 To Carry for self-treatment of febrile illness when
mg and sulfadoxime 1500 mg helps medical treatment is not available immediately
to cure an acute attack ofchloroquine Pyrimethamine-sulphadoxime single dose of 3 tablets
resistant malaria. containing 25 mg Pyrimethamine & 500 mg su lphadoxime

7. Exchange transfusion: This is given 4. M alaria vaccines (DNA vaccine,


for very high parasitemia (> 10%) and re corn binant p rotein vaccine a nd
altered mental state. transmission blocking vaccine) are still
8. Ke toconazole, miconazol e and experimental.
liposomal amphot ericin B have

> Kala Azar


been also found effective in refractory
cases. 12
C. Treatment ofChloroquine-resistant P. vivax: Kala azar is caused by Leishmania Donovani. It is
Oral metloquine or halofantrine endemic in India in Bihar, Bengal, Assam, Orissa,
UP and Madras.

95
PRACTICAL MEDICINE

The parasite occurs in two forms - amastigote (leishman­ shaped bodies with a central nucleus, eosinophilic
ial) stage in man or other vertebrates (dog, hamster, etc.) vacuole, and a flagellum.
and promastigote (leptomonad) stage in sandfly. The
amastigote form is a round or oval body, with thin cell Life Cycle (Fig. 3.35)
membrane, round or oval nucleus with kinetoplast (DNA The sandfly bites the infected man and ingests along
containing body and mitochondria) at right angles to the with blood parasites. The amastigote is transformed
nucleus, a thin axoneme from kinetoplast to the margin to promastigote in the stomach of the vector in 5-7
of the body and a vacuole. days. The promastigote multiples and is transformed
The promastigote form is found in sandfly and on during the next blood meal to another man.
culture medium. It consists of long slender spindle The parasites are taken by the phagocytes and they

Sandfly Infected while


MAN{DOG) SANDfLY
feeding
Amastigote form
Blood

Amastigolc fonn

Rciiculq-cndothdial
Sn1cm<R•·s1
Bone marrow
Mid-gut of Sandfly
--
Spleen
Liver
RETICULO­ SANDFLY
ENDOTHELIAL CYCLE
SYSTEM

''' '
�lulllpU�11lon by binary Mulllpllcallon by
res,lon blo•ryffnloo

Pro1111ntigote fonns

Sandfly biles man and


Reli<ulo-endolhollal promastigote fonns
syslem
liberated into wound
caused by the probosis

Proma�1i..:01c
rann

Days 6-9

f 19_3 35 :Life cycle of kala azar

96
-----
( 3 > Abdomen

multiply within them by binary fission. The macro patient may be emaciated and anemic with
phages filled with the parasites rupture releasing the wasting, edema, hemorrhagic manifestations,
parasites in circulation which are taken by the cells of diarrhea (GI involvement) and cough (due to
reticuloendothelial system. This leads to enlargement lung involvement).
of spleen and liver . Gamma globulins particularly
JgG is increased but the antibodies present are not Complications
protective. 1. Respiratory: Pneumonia, pulmonary tuberculosis
2. Gastrointestinal: Amebic and bacillary dysentery
Immunology
3. Cancrum oris: Ulcerative lesion near the angle
Amastigote excites a cellular reaction of histiocyte
of the mouth
proliferation followed by invasion of lymphocytes
and plasma cells by the parasites. The sensitized lym­ 4. Septic infection
phocytes destroy Leishmania-filled macrophages. The 5. Pancytopenia
increased IgG are responsible for formal gel reaction.
Similarly specific antibodies (complement fixing, Diagnosis
hemagglutinating and fluorescent) can be used for I. Direct Evidence:
diagnostic purposes. Parasites may be demonstrated by microscopic
Clinical Features examination of stained film or by culture
examination.
Incubation period varies from few days to few years
a. Microscopic examination: Blood, bone
average 3-6 months.
marrow or splenic aspirate can be examined
l. Pyrexia: This may be continuous, remittent or
under the microscope. The amastigotes
later intermittent. The fever may be preceded
within the macrophages are referral to as
by rigor or vomiting, but is not associated with
LD bodies (Leishman-Donovan bodies).
headache, prostration or sweating. In 20% cases
there may be two spikes of temperature within
24 hours (camel hump fever).
2. Splenomegaly: TI1ere is progressive enlargement
of the spleen which may extend upto the right
iliac fossa. Spleen increases in size with each ln1racellular
episode of fever. 1 leishmania
3. Hepatomegaly and Lymphadenopathy: Liver (LO bodies]
enlargement follows splenomegaly. Usually
lymph nodes are not enlarged, but in African
and Chinese form they may be enlarged.
Fig. 3.36: Le1shmania-D0novan (LD) bodies 1n monocytes
4. Skin: The skin is dry, rough, harsh and in Kala-azar
hyperpigmented. Hair is brittle and sparse. Post.
kala azar dermal leishmaniasis (PKDL) occurs b. Culture: About 1-2 ml. of blood, marrow
one year or several years after recovery. They may or splenic aspirate is cultured in NMN
develop in three forms - depigmented macular (Navy, MacNeal and Nicolle) medium
lesion like tinea versicolor, erythematous papules which consists of 2 parts of salt agar and
or erythematous nodules on ear and face (like one part of defibrinated rabbit's blood. The
nodules of leprosy) All the three types may be material for culture is inoculated into the
present in the same patient. water of condensation of the medium and
incubated at 22-24°C for 1-4 weeks. At the
5. Systemic features : Unlike in other fevers there
end of each week, a drop of condensation
is no apathy, malaise or anorexia. However the
fluid is examined for promastigote. This is

97
PRACTICAL MEDICINE

a slow method and may take one month to 2. Pentamidine isethionate: It is given in the dose
make .a diagnosis of 3-4 mg/kg. daily or on alternate days for
II. Indirect Evidence: 15 injections. Hypotension due to histamine
release may occur. This is prevented by giving
A. Blood Count: There is pancytopenia,
antihistaminics 20-30 minutes before each
but leucocytes are reduced more than
injection. It may also cause liver and kidney
erythrocytes. Eosinophils are usually
damage as well as precipitate diabetes mellitus.
absent.
3. Amphotericin B: In resistant cases of Kala azar
B. Serological Tests
it is given in the dose of 0.1-0.25 mg/kg in 5%
l. Napiers aldehyde test: One ml of serum dextrose slowly on alternate days 3-8 weeks.
is taken and to it a drop or two of 40%
formalde-hyde is added. Jellification Prevention
of milk white opacity within 2-20
I. Personal: Using mosquito nets (22 meshes/inch)
minutes occurs ifKala-azar is of over
fumigation of sleeping quarters and avoiding
3 months duration due to increased
sleeping on ground floor would help.
gamma globulins. This test is also
positive in myeloma, cirrhosis of 2. Community: Man is the reservoir of infection
liver, S Japonicum and African and treating all cases of Kala azar would help,
trypanosomiasis. However it is Measures against eradication of sandflies would
negative in cutaneous leishmaniasis. also be useful.
2. Chopra's Antimony test: 4% urea

13 Typhoid
stibamine solution is added to I
in 10 dilution of serum in distilled
water. Flocculationsoccur in positive
Definition
cases.
3. Brahmachari's test: To I ml of serum, Typhoid is an infectious disease caused by salmonella
distilled water is added. In positive typhi which is a gram negative, non-spore forming
cases a precipitate forms. bacilli.
4. Complementfixation test: This is done Epidemiology
with Witebsky. Klingenstein and
Kuhn (WKK) antigen and becomes Typhoid germs are contracted from food or drink con.
positive in 3 weeks. However, it is not taminated with excreta from carriers or patients. The
specific, being positive in tuberculosis, spread is facilitated by poor environmental hygiene.
leprosy and trypanosomiasis. Immunity following the infection is not sufficient to
prevent relapse.
5. Other serological tests: Indirect
immuno-fluorescence and enzyme Predisposing Factors
linked immuno-sorbent assay
1. Organism: A large number of organisms have
(ELISA) have also been found to be
to be ingested by healthy person to suffer from
sensitive.
typhoid. Smaller inocula may produce the
Treatment disease if the organisms are very virulent or if
the resistance of the host is poor.
l. Sodium antimony gluconate: One ml contains I 00
mg ofantimony. Daily 6 ml is given IM or IV for 2. Stomach acidity: The acid in stomach destroys
salmonella that is ingested. Hence, patients
10-15 days. In children 3 ml daily is given and
having achlorhydria (no acid in stomach) or who
in infants 2 ml daily is given. The course could
take large amounts of antacids to neutralize the
be repeated after a gap of 15 days.
acid in stomach suffer more often from typhoid.

98
- .........
_
( 3 Abdomen
3. Intestinal flora: The normal intestinal flora They do not penetrate beyond lamina propria and
produces short chain fatty acids which are multiply in the lymphoid tissues (Peyer's patches) of
lethal to salmonella. When these are reduced by the small intestine. Inflammatory changes occur with
antibiotics, the patient is more prone to typhoid. accumulation ofleucocytes. Enterotoxin liberated by
thebacteria may form abscess, which may burst causing
Pathophysiology ovoid ulcers. This may cause hemorrhage and if the
Salmonella that cause enterocolitis after ingestion, ulcer reaches the serosa, perforation occurs.
invade the mucosal cells and multiply within them.

lnjestion
---------,
Via thoracic duct into
blood stream
I
I
I
I
I Carrier

Proliferation in
small bowel ---------11.E Gall bladder-1-.J...:..-r.:�.. /

·---\
L�.•

In Peyer's Patches

DIAGNOSIS:
1st week: Blood culture
2nd week: Antibody (Widal)
3rd week: Stool culture
I
4th week: Urine cultu
:__J

Fig. 3.37 · lifecycleofenter1c fever

99
b
PRACTICAL MEDICINE

Clinical Features organism in their feces for at least one year. Usu­
ally they are typhoid patients or persons with biliary
I. Enterocolitis: In enteroco\itis, the infection
tract disease. 'Ihe gall bladder serves as a reservoir
is usually localized in the small intestines and
of infection and this carrier state is asymptomatic. It
colon. The incubation period is usually 12 - 72
may persist for lifetime without antibiotics or biliary
hours but may be up to 2 weeks.
tract surgery. Rarely, urinary carriers may be present.
l. Nausea, vomiting and an early chill are
common initially followed by colicky Investigations
abdominal pain and diarrhea of watery,
l. Culture: Salmonella organisms can be
green, offensive stools.
grown from blood culture or dot culture on
2. Blood mixed with stool and high fever may MacConkey's agar in the first week in 90% of
occur if there is involvement of colon. patient. In the second week, stool culture is more
Symptoms may subside within a week or reliable. The organism can also be isolated in
two. some cases from urine.
II. Enteric Fever: This is clinical syndrome 2. Serology: Widal test determines the agglutinins
characterized by fever, headache, prostration, against somatic (O) and flagellar (H) antigens.
cough, splenomegaly and leucopenia, caused 1his test is negative in the first week, becomes
by S. typhi or paratyphi. The incubation period positive by second or third week and may remain
is 7 14 days. The onset is insidious with the positive for a prolonged period. Hence, a single
following features: positive test is of no diagnostic value, but a
l. Fever: Usually, there is a continuous fever, demonstration of a rising titer in a patient of
which typically rises in the stepladder fever is suggestive of typhoid fever.
pattern in the first week, but it may be 3. Leucopenia: is usually present except in presence
remittent type. Rigors and sweats are not of complications or in children.
common. It is usually accompanied by dull
headache. Complications
2. Abdomen: Mild abdominal discomfort and I. Abdominal
distension occurs with nausea, vomiting
and constipation, which are followed by l. Hemorrhage may occur at the end of
diarrhea (pea soup stools). Hepatomegaly the second week and is characterized by
and splenomegaly occurs. black stools, tachycardia, hypotension and
diarrhea. There is no abdominal pain or
3. Rose-spots: These are erythematous,
rigidity or obliteration ofliver dullness like
maculopapular lesions 2 4 mm in diameter
in intestinal perforation. Transfusions may
which blanch on pressure usually seen on
be needed if there is massive blood loss.
the upper abdomen, back and chest. They
occur in the first or second week. 2. Perforation may occur at the end of the
4. Miscellaneous: Cough due to 'typhoid second week or in the third week. It is
bronchitis' and relative bradycardia may characterized by acute pain in the lower
occur. abdomen, vomiting, abdominal distension,
hypotension and tachycardia. 'Ihe liver
Ill. Clinical course: ln the pre-antibiotic era,
dullness may be obliterated and the
the patient gradually recovered or developed
abdomen becomes tender, rigid and silent
complications in the third or fourth week.
(absent peristalsis).
Relapse occurs in 5-10% of untreated patients
and 15-20% of patients on treatment. 3. Tympanitis
4. Cholecystitis
Chronic Carrier State
5. Splenic infarction
Chronic carriers are those who excrete salmonella

100
( 3; Abdomen

6. Rarely-appendicitis, intussusception and regularly observed to detect any


pyogenic liver abscess serious complications.
II. Extra-abdominal 4. Antipyretics: Fever and body ache can
1. Myocarditis, endocarditis be treated with paracetamol and tepid
2. Osteomyelitis, arthritis, typhoid spine and sponging.
Zenker's degeneration of rectus abdominis B. Antibiotics
3. Pulmonary infection and embolism I. Conventional: O r a l o r IV
4. Thrombophlebitis ch/oramphenicol 500 mg 6 hourly
5. Electrolyte imbalance, shock and acute in the first week followed by 500
renal failure mg 8 hourly for 2 more weeks. Co
6. Neurological: Meningo encephalitis, trimoxazole 2 tablets TDS, A111oxycilli11
meningism, cranial nerve palsies, myelitis, I gm 6 hourly or Ampicillin 500 mg 6
ascending paralysis, Parki nsonism, hourly are other useful drugs.
athetosis, cerebellar ataxia, neuritis 2. Quinolones: Ciprofloxacin 200 mg IV
7. Typhoid state: This ischaracterized by coma 8-12 hourly in a drip has been found
vigil, muttering delirium, carphologia to be very useful in chloramphenicol
(picking up clothes in bed) and subsultus resistant typhoid fever, If the patient
tendinosis is not vomiting it can be given orally
8. Psychosis in the dose of 500 mg 8-12 hourly.
Ofloxacin 200 mg daily for 7-10 days
Treatment is also useful.
I. ENTEROCOLITIS:Thisisa self limitingdisease 3. Cephalosporins: The drug of choice
which requires only symptomatic treatment like is Ceftriaxone 3-4 gm once daily for 7
fluid and electrolyte balance antiperistalticagents days or 80 mg/kg once daily for 5 days.
etc. Antibiotics are used only if there is impaired It is as effective as chloramphenicol
host resistance. in reducing fever in typhoid. Other
II. Enteric Fever: cephalosporins are also effective (See
A. General Measures: Ch. 15)
l. Rest: Patients with enteric fever C. Steroids: In the absence of intestinal
must be given complete bedrest and complications, steroids can be used for
preferably hospitalized because the severe toxicity, hyperpyrexia, septicemia
incidence of complications is more in and haemolysis along with antibiotics, It
patients who have not taken adequate is given as prednisolone 30-60 mg daily in
rest. divided doses with antacids.
2. Diet: For the first dew days a semi­ D. Chronic carrier: Ampicillin 1 gm 6 hourly
solid diet is advised and later a for one week followed by I gm 8 hourly for
low-roughage, high-calorie diet like 6-12 weeks is needed. Cholecystectomy
bananas is advised. This is to decrease may be advised for biliary carriers.
the intestinal content in presence of Prevention
friable intestines.
1. Typhoid can be prevented by improving
3. Nursing care: The general care of the
personal hygiene, sanitary disposal of excreta,
patient includes good nursing and
pasteurization of milk, adequate water protection
disinfection of excreta and bed linen
and identification, isolation and treatment of
in 2% Lysol. Fluid and electrolyte
chronic carriers.
balance and vital signs must be

101
PRACTICAL MEDICINE

2. Vaccine: Table 3.13 : French American British


a. Injectable Vaccine : A vaccine (TAB) (FAB) Classification
prepared from heat killed S. typhi organisms Acute Leukemias (>20% blasts in bone marrow)
is available for immunization of high risk Acute myeloid leukemia (AML): MO to M7
persons. It is given in the dose of 0.5 ml Acute lymphoid leukemia (ALL): L 1 to L3
subcutaneously and repeated 4 weeks later Chronic Leukemias ( <1 0% blasts on smear)
in the dose of l .O ml. It gives protection for Chronic myeloid leukemias (CML)
2 years. Given >2 yrs. of age. Chronic lymphoid leukemias (CLL)

b. Oral Vaccine (Ty2la) : Oral Vaccine - l Clinical Features in AML and ALL
tablet on alternate days for 4 doses.
Contraindicated in pregnancy in children I. Due to bone marrow failure
<6 yrs. of age. Repeated every 5 years. 1. Due to anemia: Fatigue, pallor, dysnoea
2. Bleeding manifestations: Easy bruising,
petechiae, purpura, bleeding from various
14 Leukemia sites and in various tissues.
Leukemia is a disease of unknown etiology, character­ 3. Infections and/or fever: Infective lesions
ized by an uncontrollable and abnormal proliferation in mouth, throat, respiratory tract, skin.
of leucocytes and their precursors, which infiltrate II. Due to Organ infiltration
the body tissues. 1. Bony tenderness especially of the sternum
Acute Leukemias 2. Hepatosplenomegaly & lymphadenopathy
( mediastinal,axillary, inguinal and cervical)
Acute leukemia is a hematological neoplasm character­
ized by proliferation of malignant hemopoietic blast 3. CNS: Hemorrhage, meningeal infiltration
cells. There should be more than 20% blasts cells in and multiple cranial nerve palsies
the bone marrow at clinical presentation. Untreated, 4. Skin or orbit: Chloromas
acute leukemias are rapidly fatal, median survival 5. Kidneys: Renal failure
being two months. Death occurs from infection or
6. Heart: Cardiomyopathy and pericarditis
hemorrhage or both.
7. Fundus: Roth spots, papilledema
Acute leukemias are subdivided into acute myeloid
leukemia (AML) and acute lymphoid leukemia (ALL) 8. Testes: Swelling, particularly in ALL
on the basis of the blasts present, whether myeloblasts 9. Gum hypertrophy in AML M4/M5
or lymphoblasts. The morphology, clinical features,
Peripheral Blood Picture in AML and ALL
cytochemistry, immunophenotypingand molecular
genetics are used to subdivide AML and ALL into l. Anemia: Normochromic, normocytic
their subtyp es (Tables 3.14, 3.15, 12.5, 12.6) 2. Thrombocytopenia; DIC may be present in M3
Total WBC count may be increased, normal or
Acute Myeloid Leukemia (AML) 3.
low. Neutropenia is present.
AML occurs at all ages. AML is subdivided into 8 4. Variable number of blast cells may be present.
subtypes (Table l l.2) based on morphology and cy­ "Smear" cells may be present in some ALLs.
tochemistry according to FAB classification.
Bone Marrow in AML and ALL
Acute lymphoid leukemia (ALL)
1. Cellularity: Usually hypercellular
ALL occurs primarily in children and sometimes after
2. Leukemic blast cells > 30% should be present.
the age of 40. FAB classification subdivides ALL into
3 subtypes (Table 11.3). 3. Erythroid cells and megakaryocytes reduced.

102
( 3) Abdomen

Table 3.14: Classification of Acute Myeloid Leukemia (AML)


subtypes (FAB) Morphology (Bone Marrow) Common Clinical Features Diagnostic Tests/Cytochemistry

MO Large agranular blasts Myeloperoxidase - (or <3%


Mini mally Myeloid by immunophenotyping positive and+ at electron
Differentiated microscopic level)
PAS- (or <3% positive)

M1 Least differentiated blasts (>90%of Myeloperoxidase+ (> 3%)


Myeloblastic NEC), granular or agranular. Auer PAS+(diffuse)
without rods+
maturation

M2 Differentiation to promyelocytess 8;21 Translocation Myeloperoxidase ++


Myeloblastic with Blasts (>30- 89%of NEC) Common in young patients PAS+ (diffuse)
maturation Monocytic cells <20%
Auerrods+
Abnormal neutrophils

M3 Bundles ofrod-like structures (Su Itan Bleeding tendency due to DIC Myeloperoxidase+++
Promyelocytic bodies/"Faggots• in promyelocytes. and thrombocytopenia. PAS+ (diffuse)
Auer rods+ Bilobed nuclei. Young patients.
Microgranular variant also present 15; 17Translocation

M4 Mixture of blasts (>30% ofNEC) Gum hyperplasia Myeloperoxidase ++ PAS +


Myelomonocytic prornye1ocytic and rnonocytic (diffuse)
differentiation(>20% monocytic Non-specific esterase +
lineage) (monocytic cells only)
Serum & urinary lysozyme
increased

MS > 80% monocytoid cells. Gum hyperplasia. Non-specific esterase+++


MSa: Monoblastic MSa: Monoblasts only Hemorrhagic rash on Myeloperoxidase - PAS+ (diffuse)
MSb: Monocytic MSb: Monoblasts differentiated into skin. Lymphadenopathy, Serum & urinary lysozyme
prornonocytes and monocytic cells hepatosplenomegaly. increased
M6 Over 50% cells are erythroid Erythroblasts PAS + (block)
Erythroleukemia precursors with bizarre Only myeloblasts are
dyserythropoietic forms Myeloperoxidase +
Myeloblasts (with Auer rods) 30%
after excluding eryth roid cells
M7 Fibrosis of bone marrow, Blood shows pancytopenia PAS+ (granular)
Megakaryoblastic rnegakaryoblasts >30% Myeloperoxidase-
Platelet peroxidase+ (EM)
Acid phosphatase++ (diffuse)
NEC: Non-erythroid cells; PAS: Periodic Acid-Schiff

Treatment L-Asparaginase 600 units/m2 SC biweekly


for 1 month.
I. Chemotherapy Prednisolone 40 mg/m 2 orally daily for I
month
Chemotherapy for ALL
2. Vincristine 1.4 mg/m 2 IV weekly for 1
A. Induction: Combination chemotherapy is used. month.
Any one of the two regime may be used. Doxorubicin (Adriamycin) 40 mg/m2 IV
1. Vincristine 1.4 mg/m2 IV every week for 1 weekly for 1 month.
month.

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PRACTICAL MEDICINE

Table 3.15 : Classification of Acute Lymphoblastic Leukemias (ALL)


FAB Classification Morphology Immunological Diagnostic Tests Prominent clinical
Sub-Type features

Ll Small uniform blast cells with 6-ALL or T-ALL c-ALL antigen + T-ALL type shows
Small, monomorphic. large regular nucleus surrounded (Null-ALLC-ALL TdT + thymic enlargement
More common in by a thin rim of cytoplasm. rare) PAS+ blocks in
children cytoplasm.

L2 Heterogenous size of blasts with Mostly T-ALL Acid phosphatase+ T-cell type shows
Large,heterogenous. prominent nucleoli and relatively C-ALL or Null- TdT+ thymic enlargement.
More common in adults abundant cytoplasm. ALL Anti-T +

L3 Large blasts with multiple B-ALL Surface immunoglobulin Lymphdenopathy


Burkitt cell-type small vacuoles throughout a + Spleen & liver
uncommon basophilic cytoplasm and over a TdT - enlargement.
homogenous nucleus Oil Red O +
TdT: Nuclear enzyme terminal deoxynucleotide transferase; PAS:Periodic acid-Schiff

ALL with less than 5% blast cells). Ifit is not achieved,


one more cycle of chemotherapy is given or
alternative treatment is tried.
B. CNS prophylaxis: Intrathecal methotrexate
Induction CNS Maintenance 15 mg/m2 every week for 4-8 weeks following
Prophylaxis complete remission, or cranial irradiation l 800-
2400 rads. may be given to reduce the chance of
neurological involvement.
Vincristine C. Intensification: Methotrexate + Leucovorin
L-Asparaginase Intrathecal
Prednisolone Methotrexate 6-Mercaptopurine D. Maintenance: This includes administration
Methotrexate of low dose chemotherapy over a period of 36
months. 6 Mercaptopurine 75 mg/m 1 daily is
OR OR given orally, along with oral methotrexate 20
mg/m2 once a week. During maintenance period,
Vincristine
combination chemotherapy given for induction
Cranial
Adriamycin irradiation is also used intermittently. Ifthe patient remains
Prednisolone in continuous remission for 3 years maintenance
Prednisolone 40 mg/m2 orally daily for I treatment is stopped.
month with either of the regimes. Result of treatment: 80% of patients go into
The following is ensured: complete remission and 40% are cured. The
prognosis depends on age, initial total count,
a. Adequate hydration and good urine
surface marker characteristics (T-cell/B-cell
output.
have bad prognosis), mediastinal mass.
b. Alkalinization of urine with soda­
bicarb 2.0 gm four times a day. Chemotherapy for AML
c.Allopurinol l 00 mg three times a day A. Induction:
to prevent uric acid nephropathy. DAT regime is given which consisting of:
After a course of the above medicines, bone­ Daunorubicin 45 mg/m 2 IV bolus on days 1, 2
marrow aspiration is done to decide whether and 3 or days 4,5 and 6.
complete remission is achieved (Complete
Cytosine arabinoside 100 mg/m 2/ day by
remission means normocellular bone-marrow
continuous IV infusion for 7 days.

104
>
( 3 Abdomen

1hioguanine 100 mg/m2 orally twice a day for D. Allopurinol before starting antileukemic
7 days. Bone-marrow aspiration is done after 3 agents to prevent hyperuricemia.
weeks and if evidence ofleukemia persists, the E. Mainte nance of good oral hygiene,
above cycle is repeated. adequate nutrition, electrolyte and acid
B. Consolidation therapy: This includes 2-6 base disorders.
courses of combination therapy used for
induction. Recently use ofhigher dose ofcytosine Ill. lmmunotherapy:
arabinoside with daunorubicin or combination This is used because a patient in complete
of non-cross resistant drugs has been found to remission reacts to his blast cells as though they
be ofsome benefit. were foreign tissue. It may be attempted with
C. Maintenance therapy: BCG or allogenic irradiated leukemic cells.
Cytosine arabinoside 60 mg/m2 once a week and Chronic Leukemia
6- 'Ihioguanine 40 mg/m2 twice a day orally for 4
days/week is given for 1-3 years. This increases Chronic leukemias have a more indolent behavior
the duration ofdisease-free survival. and better prognosis than acute leukemias. Chronic
lymphoid leukemia ( CLL) tends to occur in the elderly.
D. Bone-marrow transplant: This has a high cura­
Chronic myeloid leukemia (CML) is more common
tive potential. It is done following complete
remission. However, its limitations are high cost in middle age. Juvenile CML occurs in children below
and non-availability of matched donors. 3 years of age.
Results of treatment: Sixty percent achieve Clinical features in CML and CLL
complete remission but only 20% get cured.
I. Due to anemia: Pallor, fatigue, dysnea, etc.
E. All-trans retinoic acid (ATRA) is used for the
IL Due to Organ infiltration:
treatment of acute promyelocytic leukemia
(APML) 1. Hepatosplenomegaly
2. Lymphadenopathy: Usually cervical,
H. Supportive Treatment mediastinal and axillary. Lymphadeno­
A. Blood/Platelet/ Granulocyte transfusions pathy is more common with CLL.
B. Combination of higher antibiotics like 3. Cardiorespiratory: Pulmonary congestion,
aminoglycoside (gentamicin, amikacin, infiltration or collapse. Pleural effusion.
etc.) with cephalosporins (cefotaxime, 4. CNS: Meningeal infiltration, cranial nerve
cefazolin, ceftazidime, etc. palsies and paraplegia
C. Treatment of oral, gastrointestinal and 5. Skin: Pruritus and nodules, gout
systemic fungal infections. III. Duetothrombocytopenia: Bleeding tendencies
AML (epistaxis, hematemesis, etc.) in CLL. Platelets
are normal or increased in CML.
IV. Due to increased metabolism: Fever, weight
Consolidation Mainlenance loss, malaise, perspiration and gout.

Peripheral Blood Picture in CML and CLL


Cytosine arabinoside Cytosine Cytosine
Daunorubicin arabinoside arabinoside 1. Anemia: Normochromic, normocytic
Thioguanine Daunorubicin Thioguanine
Thioguanine 2. Leucocytes increased
InCML:
Bone Morrow Chronic phase shows I ,00,000-5,00,000/cc.
Trans lantation
with early granu!ocyte cells (metamyelocyte,

105
PRACTICAL MEDICINE

myelo-cyte, promyelocyte, band forms). Only 3. Hydroxyurea 1-2 gm orally till WBC
occasional blast cells is seen (<10%). Neutrophil count falls to 10,000/cm. It is used
alkaline phosphatase is markedly reduced. in patients with chronic myeloid
Blast crisis in CML is indicated by an increasing leukemia not responding to busulfan.
basophil count. It may be myeloid or lymphoid B. Radiotherapy: This may be useful as a
in origin. Myeloid blast crisis resembles AML, symptomatic measure to reduce the size of
but Auer rods are not seen. Lymphoid blast massively enlarged spleen, when cytotoxic
crisis is rarer and shows lymphoblasts with drugs have failed.
characteristics such as TdT positivity. C. Splenectomy: This may be required when
InCLL: enlarged spleen is causing symptoms.
50,000-2,00,000/cc. Majority(>90%) are mature D. Bone Marrow Transplantation is the only
small lymphocytes. "Smudge" or "smear" cells curative treatment.
(degenerative forms) may be present. Absolute II. Chronic Lymphatic Leukemia
neutrophil count is normal. Neutropenia occurs
A. Chemotherapy:
in advanced CLL.
1. Chlorambucil 6-10 mg/day for 14
3. Platelets are normal or low.
days with a break of 14 days. When
Bone Marrow in CML and CLL WBC count falls below 25,000/c.c.
the dose is reduced to 2-4 mg/day. It
1. Cellularity: Hypercellular is discontinued when the WBC count
2. Erythropoiesis is normoblastic, sometimes falls below 1,000-10,000/c.c.
megaloblastic. Reduced erythroid precursors.
2. Cyclophosphamide: 2-3 mg/kg. I.V. for
3. Leucopoiesis: 6 days.
In CML bone-marrow is hypercellular with B. Radiotherapy: T his is useful for large
myeloid: erythroid ratio increased. There may granular masses if they cause symptoms.
be myelocytes, promyelocytes, eosinophils and
C. Steroids: Prednisolone 40 mg/day may
basophils. Blast cells or promyelocyte more than
improve hemoglobin or platelet count.
30% suggests blast crisis in CML.
In CLL both small and large lymphocytes D. General supportive measures:
are diffusely infiltrated (25-95%). Myeloid 1. Blood transfusion
precursors are reduced. 2. Antibiotics
4. Megakaryocytes are prominent in CML and 3. Gamma globulins
reduced in CLL.
5. Cytogenetics: Philadelphia chromosome may Hairy Cell Leukemia (HCL)
be present in myeloid and erythroid precursor Hairy cell leukemia is a rare type of chronic leukemia
cells in 70-90% of CML cases. with pancytopenia and marked splenomegalywithout
lymphadenopathy. The typical "hairy" lymphoid cells of
Treatment
B-cell origin are seen in the peripheral blood and in
I. Chronic Myeloid Leukemia bone marrow aspirates and splenic imprints. These
A. Chemotherapy:· cells also show a characteristic strong postive tartaric
1. Imatinib Mesylate 400 - 800 mg daily acid resistant acid phosphatase (TRAP) reaction.
is the drug of choice. Newer drugs if
there is imatinib failure.
2. Busulfan 4 mg/day orally, reduced to 15 Malignant Lymphoma
2 mg/day when WBC count falls to Definition : Malignant Lymphoma refers to a large
30,000/c.c.

106
3 Abdomen

variety of malignant lymphoproliferative disorders IV. Diffuse involvement of extralymphatic organs or


arising from lymphoid components of various organs. tissues with or without associated lymph node
They are classified as Hodgkin's and Non-Hodgkin's involvement.
lymphoma. Each stage is sub-divided into two categories.
Hodgkin's Lymphoma A. For those without symptoms.
B. For those with symptoms, e.g. fever, weight
Definition loss
Hodgkin's disease is characterized by presence of Reed
Treatment
Sternberg cell and is caused by either viral infection
or deranged immune mechanism. I. Radiotherapy: Most effective for stages I and II.
II. Chemotherapy: For patients with stages III and
Clinical Features
IV. MOPP or ABVD regime may be used.
I. Lymphadenopathy: Cervical, mediastinal,
A. MOPP regime
axillary and inguinal. Unilateral initially, later
bilateral. The glands are painless, discrete and 1. Mustine hydrochloride 6 mg/meter2
firm. I.V. on Day 1 and 8.
II. Hepatosplenomegaly: Moderate to marked non­ 2. Oncovin (Vincristine) 1.4 mg/meter2
tender enlargement of liver and spleen. I.V. on Day 1 and 8.
III. Constitutional: Fever, night sweats, weight loss, 3. Procarbazine 100 mg/meter2 orally
anemia and cachexia may occur. Fever may from Day 1 to 14.
be remittent, continuous, or Pel Ebstein's type 4. Prednisolone 40 mg/meter2 orally
(Fever for several days interrupted by periods from Day 1 to 14.
of remission). No drugs are given from Day 15-28.
IV. Due to infiltration or metastasis This is one course.
A. Skin: Pruritus, erythema and herpes zoster Six such courses may be given.
B. Bones: Pain, tenderness and sclerosis (ivory B. ABVD regime
vertebrae)
1. Adriamycin 25 mg/m2 IV bolus on
C. CNS: Pain, paresthesia and paraplegia day 1,8,14
D. GI: Jaundice, ascites and intestinal 2. Bleomycin 10 mg/m2 IV boluson day
obstruction 1,14
F. Genitourinary: Hematuria, retention of 3. Vinblastine 6 mg/m2 IV bolus on day
urine and backache 1,8,14
Stages (ANN Arbor Staging) 4. Dacarbazine 375 mg/m2 IV bolus on
I. Involvement of a single lymph node region (I) day 1,14
or of a single extra lymphatic organ (le). The cycle should be repeated on 29th day.
II. Involvement of two or more lymph node regions III. Splenectomy: Laparotomy and splenectomy is
on the same side of the diaphragm (II) or advocated in many patients except with stage
involvement of extralymphatic organ and one IV disease.
or more lymph regions on the same side of the Advantages:
diaphragm (Ile).
A. It can be determined whether spleen is
III. Involvement of lymph node regions on both sides involved.
of the diaphragm (III). It may be accomp-anied
B. It prevents recurrence in spleen, which is
by involvement of spleen (IIIs) or by involvement
difficult to treat with radiotherapy due to the
of extralymphatic organs (Ille).
close proximity of left kidney and lung.

107
PRACTICAL MEDICINE

Non-Hodgkin's Lymphomas is favorable or unfavorable cytologic pattern. Radio­


therapy and chemotherapy are useful in majority of
Definition: Non�Hodgkin's lymphomas (NHL) are a
the patients. However, surgery is useful only in selected
heterogenous disease entity characterized by involve­
cases with primary extranodal lesions.
ment of variety of anatomical sites other than lymph
nodes e.g. skin, gastrointestinal tract, bone marrow etc. I. Favorable NHL
Therapeutic interventions are postponed until
Clinical Features symptoms develop. Combination chemotherapy
The clinical presentation has many simjarities to (Table) or total body irradiation is useful. The
Hodgkin's disease. However, the pattern of spread clinical course is characterized by continuous
is variable and patients may present with disease in pattern of remission and relapse over a period
organs other than lymph nodes or with leukemic of several years.
manifestations. Table 3.17 : Combination Chemotherapy
l. Lymphadenopathy: Asymmetrical painless forNHL
enlargement of the peripheral lymph node may Regime Drug Duration
occur. Retroperitoneal and mesenteric lymph I. CVP: Cytoxan 600 mg/m2 IV Day 1 and 8
nodes are frequently affected. Vincristine 1 .4 mg/m 2 IV Day 1 and 8
2. Hepatosplenomegaly: Spleen is usually Predn isolone 40 mg/m 2 ora I Days 1 15
markedly enlarged. Liver is also enlarged. II. CHOP; Cytoxan 600-mg/m2 IV Day 1 and8
Adriamycin 50 mg/m2 IV Dayl
3. Anemia: This occurs due to involvement of
Vincristine 1 .4 mg/m 2 1V Dayl and8
the bone marrow, hypersplenism, hemolysis or Prednisolone 40 mg/m 2 oraI Days 1-15
autoimmune disease.
II. Unfavorable NHL
4. Gastrointestinal symptoms: Abdominal
Chemotherapy is the mainstay of treatment
pain, nausea, vomiting, diarrhea or intestinal
in diffuse lymphoma. The goal is to achieve
obstruction may occur due to involvement of
complete remission, as lesser response is always
the gastrointestinal tract.
associated with poor prognosis. Localized
5. Skin: Skin deposits may occur and skin may be disease is potential curable by radiotherapy,
primarily involved in two unusual closely related however such localied disease is rare.
T lymphocytic lymphomas -Mycosis fungoides
and Sezary syndrome. Burkitt's Lymphoma
I. This is B lymphoblastic lymphoma found in
Treatment
young African children
The initial treatment will depend upon whether there 2. It may result from inability of the immune
Table 3.16 : Classification of NHL response to deal with Epstein Barr Virus.
(International Working Formulation) 3. It usually produces massive jaw lesions, extra­
Low Grade Intermediate hlighGrode nodal abdominal involvement, ovarian tumors

,. ,.
Grade and lymphoid tissues of cervical and ileocecal
1. Small Follicular Large Cell region.
lymphocytic Large Cell tmmunoblastic
4. Histologically there is characteristic "starry sky"
2. FollicularSmall 2. Diffuse Sma It 2. Lymphoblastic appearance ofB lymphoblastic lymphomas with
Cleaved Cell Cleaved Cell
scattered histiocytic reticular cells.
3. Follicular 3. Diffuse Mixed 3. Small Non-
Mixed Small Small and cleaved Cell Mycosis Fungoides
Cleaved and Large Cell (Burkitt's and
Large Cell Non-Burkitt's) Mycosis fungoides, a chronic lymphoma of the skin,
4. Diffuse Large 4. Miscellaneous has three stages:
Cell (Mycosis fungoides, I. Premycotic stage: Lesions similar to eczema or
Histiocytic)
psoriasis

108
( 3 > Abdomen

2. Infiltrative or Plaque stage: This is with (Family Retroviridae, Subfamily Lentivirus). HIV-1
generalized exfoliative erythroderma and is the most common cause worldwide. HIV-1 has
invasion of the blood by typical convoluted many different strains due to mutations. There are
lymphoid cells {Sezary syndrome) three groups M (major, subtypes A-J), 0 {outlier,
3. Nodular or tumour stage: Deeper invasion by rare) and N (very rare). In India, Group M subtype
the tumour and infiltration of lymph nodes and C predominates.
other organs.
Transmission of HIV

16 > Human l. Sexual transmission


Intimate homosexual or heterosexual contactwith
Immunodeficiency an infected person can cause transmission ofHIV.
Virus (HIV) Disease: High risk of transmission is with:receptive anal
Acquired Immune
Deficiency Syndrome
(AIDS)
HIV disease is an infectious disease cause by the hu­
man immunodeficiency virus.
AIDS occurs at a late stage of HIV infection, when
the CD4+ T-lymphocyte count is <200/µL and there
is documentation of an AIDS-defining condition
(See Table).
Definition of HIV Infection
According to the HIV infection case definition(CDC
2008), a reportable case of HIV infection among adults
and adolescents aged �13 years is categorized by in­
creasing severity as Stage 1, Stage 2, Stage 3 (AIDS) or
Stage unknown as shown in the table below:
Morphology of HIV RC'\·�nr tr1111ns(ripf:i11St
rnzym('

P7/9 (g<>nomit R!'ri".A wilh


Etiology rtbonud�prolrin 5urrou11d)

AIDS is caused by an infection with HIV-1 or HIV-2 Fig 3.38 · Schematic illustration of HIV components

Table 3.18: Staging of HIV Infection


Stage Lab confirmation of CD4+ T-lymphocyte count CD4+ T-lymphocyte Clinical Evidence'
HIV infection per pl percentage
(T4) (%CD4)
Stage 1 Confirmed Positive And Or None required (but no AIDS-defining
T4:�500 %CD4:�29 condition)
Stage2 Confirmed Positive And Or None required (but no Al DS-defini ng
T4:200-499 %CD4:14-28 condition)
Stage 3 Confirmed Positive And Or Or Documentation of an AlDS­
T4:<200 %CD4:<14 defining condition
Stage Confirmed Positive No information No information And No information on presence of
Unknown an AIDS-defining condition

109
PRACTICAL MEDICINE

Table 3.19: AIDS Defining Conditions for Table 3.20 : Definition of AIDS in adults
Adults and Adolescents <13 yrs (as per CONFIRMED HIV INFECTION WITH:
CDC) Clinical diagnosis (presumptive or definitive) of any AIDS­
1. Candidiasis: esophagus, trachea, bronchi or lungs Defining condition (Table 3.19)
OR
2. Cervical cancer: invasive
CD4 count< 200/ µL or %CD4 <14 in asymptomatic adults
3. Coccidioidomycosis, disseminated or extra or children aged>5 years
pulmonary
4. Cryptococcosis - extra pulmonary following skin puncture from a sharp object that
5. Cryptosporidiosis with diarrhea persisting for> 1 is contaminated with blood from an HIV positive
month patient is 0.3% and after mucous membrane
6. Cytomegalovirus disease (other than liver, spleen, exposure 0.09%. (Similar risk for HBV
lymph nodes) transmission is 6-30% and HCV transmission
7. Cytomegalovirus retinitis (with loss of vision) is 1.8%).
8. Encephalopathy:HIV-related Very low risk:Transmission of HIV from an
9. Herpes simplex: Chronic ulcers lasting> 1 month or infected health care worker to patients through
bronchitis, pneumonitis, or esophagitis invasive procedures.
10. Histoplasmosis: Extra pulmonary or disseminated
No risk: Saliva, tears, sweat, urine cannot cause
11. lsosporiasis with diarrhea persisting > 1 month transmission ofHIV. The virus cannot be passed
12. Kaposi's sarcoma through casual or family contact or by insects
13. Lymphoma: Burkitt's such as mosquitoes.
14. Lymphoma: Lymphoblastic 3. Maternal-fetal/infant transmission
15. Lymphoma: Primary, of brain Mother to child risk of transmission is 20-30%
16. Mycobacterium avium complex or M. kansasii before birth. The risk increases to 50-65% during
17. Mycobacterium tuberculosis, any site (pulmonary, birth and 10-20% via breast milk. A single dose of
disseminated or extrapulmonary) Nevirapine given to the mother at onset of labor
18. Mycobacterial infection: other species or unidentified and a single dose to the infant after birth reduces
species, extrapulmonary or disseminated
the risk of HIV transmission. Breast-feeding
19. Pneumocystisjirovecci (carinii)pneumonia should be avoided. However, in developing
20. Pneumonia: recurrent countries like India, breast-feeding prevents
21. Progressive multifocal leucoencephalopathy infectious diseases and provides immunity to the
22. Salmonella septicemia: Recurrent child, and is therefore advocated after counseling
23. Toxoplasmosis: brain the mother.
24. Wasting syndrome due to HIV
Pathophysiology and
intercourse, vaginal intercourse (male to female lmmunopathogenesis
higher than female to male), associated STDs or The main action of HIV is to cause the quantitative
genital ulceration. Lower risk of transmission is and qualitative deficiency of a subset of lymphocytes
with oral sex and circumcised males. referred to as T4 (CD4+) helper/inducer lymphocytes.
2. Transmission by blood, blood products or other These lymphocytes express the CD4 cellular receptor
body fluids for HIV on their cell surfacealong with the coreceptors
High-risk: IV drug users who share contaminated (e.g. CCR5, CXCR4). The destruction of these lympho­
needles, hemophiliacs, thalassemics and other cytes leads in turn to suppression or compromise in
transfusion recipients, organ transplant patients. the function of host cellular defense mechanisms, not
only to HIV but also to opportunistic infectious agents.
Low-risk: Health care workers and laboratory
personnel who work with HIV-infected Although the CD4+ T lymphocyte and CD4+ mono­
specimens. The risk of transmission of HIV cyte lineage are the principal cellular targets, HIV can

110
( 3 > Abdomen

6. Integration 1
1· 2 & 3 4. Reverse 1 7 & 8. Vir al
into host I transcription &
Binding.
entry & ;
fusion
,.-::::===:t:=====::::JC::::::::::====!:====:::-
transcription

Viral 5. Tra)tsportation
genome I translation

:
Coreceptors I RNA 1
CCR5, CXCR4 � :
:

f2y �
i = -4
!

Genomic DNA

9 & 10.
Budding &
cleavage
Antigen
(Receptor) 1-------'------- --I-------.J....-----.:: ••
I I
Drugs& Fusion I CCRS 1NRTI and NNRTI I
lntegrase Protease
Inhibitors I Antagonist IZidovudine Nevirapine I Inhibitors
Mechanism I Didanosine De laviridinel Raltegravir
Inhibitors
Enfuviritde l Maraviroc Saquinavir
ofAction I
I
: Zakitabine Efavirenz I Retonavir

I 1 Stavudine : tndinavir
1 Lamivudine I Nelfinavir
.
IAbacavir .I

F,g.3 39· Repl1cat1on Cycle ofHIVand Drugs targeting different stage of the cycle (Also Refer Ch 15)

1. BIN DI NG: HIV binds via the viral envelope protein gp 120 to the CD4 receptor on the target host eel I.
2. CORECEPTORS (CCR5 and CXCR4) facilitate entry of virus into the host cell.
3. FUSION of the virus with the host cell membrane and internalization of pre-integration complex (viral RNA and enzymes
surrounded by capsid protein)
4. REVERSETRANSCRIPTASE ENZYME converts the viral RNA genome to double stranded DNA.
5. TRANSPORTATION of the DNA to the host nucleus.
6. IN TEGRATION into the host genome by viral enzyme integrase. The HIV provirus remains latent at this stage until the
infected cell is activated by a number of cellular and viral factors. This is the reason for the interval between the time of
infection and disease expression.
7. TRANSCRIPTION ofprovirus DNA into viral rnessenger(mRNA) and genomic RNA.
8. TRANSLATION of m RNA into proteins.
9. BUDDING: The viral proteins, enzymes and genomic RNA are assembled at the cell membrane and budding of the progeny
virus occurs at special regions of the host cell membrane.
10. RELEASE: The viral enzyme protease catalyses the release of mature virions from the host cell. The vi rions infect other host
cells that express CD4 receptors.

potentially infect virtually any cell that expresses CD4 Immune Abnormalities in HIV Disease
(e.g. T and B lymphocytes, macrophages, astrocytes,
A broad range of immune abnormalities has been
microglial cells, Langerhans' cells, fibroblasts, Chro­
documented in HIV-infected patients. These include
maffin cells, dendritic cells, alveolar macrophages,
both quantitative and qualitative defects in lymphocyte,
thymus cells).
monocyte/macrophage, and natural killer (NK) cell
Immune Response to HIV Infection function, as well as the development of autoimmune
phenomena.
Both humoral and cellular immune responses to HIV
develop soon after primary infection.

111
PRACTICAL MEDICINE

Laboratory Tests for Diagnosis of HIV to appear within 2 weeks of infection, and the
Infection period of time between initial infection and the
development of detectable antibodies is rarely
Table 3.21; Laboratory Criteria for HIV longer than 3 months (window period).
Infection for Adults
The CDC criteria for a positive interpretation of
Positive result from an HIV antibody screening test
Western Blot test is the presence of antibodies to
confirmed by a positive result from a supplemental HIV
antibody test any two of three proteins p24, gp41 and gp 160/
gp 120.
And/Or
"Indeterminate" results are repeated after 4-6
Positive result from any of the following HIV virologic
(i.e,, non•antibody)tests: HIV nucleic acid (DNA or RNA)
weeks.
detection test, HIV p24 antigen test or HIV isolation. 3. Antigen Detection: The detection of HIV
1. Antibody Screening Tests: The standard by the p24 antigen capture assay, an ELISA­
screening test for HIV infection is the detection type assay, in serum or CSF is the key to early
of anti-HIV antibodies in the patient's serum diagnosis. The p24 antigen is a soluble protein
using enzyme·linked immunosorbent assay from the core of the virus. Plasma p24 antigen
(ELISA or EIA). HIV-1/HIV-2 combined EIA levels rise during the first few weeks following
assays are now being used worldwide. This test infection, prior to the appearance of anti-p24
is highly sensitive (>99.5%) but not optimally antibodies. The antigen may be detected for upto
specific. False positive results can occur in cases six weeks and then disappears with antibody
of: antibodies to class 11 antigens, autoantibodies, sero-conversion. The antigen is not detectable
hepatic disease, recent influenza vaccination, during the asymptomatic clinically silent phase
acute viral infectionsand children < 18 months for a variable period of upto 10 years or more.
whose mothers are HIV-infected The reappearance of p24 antigen precedes onset
of the symptomatic phase of AIDS.
2. HIV Antibody Test for confirmation of
positive ELISA tests is done by Western Blot 4. HIV DNA:Polymerase chain reaction (PCR)
(immunoblotting) assay or immunofluorescence techniquesare used to detect very low levels of
assay. It tests the presence of antibodies in the viral DNA integrated into the host genome.
patients' serum against HIV antigens of specific 5. HIV RNA levelsin plasma or serum (plasma
molecular weights. Antibodies to HIV begin viral load or PVL) are determined by RT-PCR

Level
or
Ag/Ab

Infection lweoks)

Clinical TIME
I ················-····............. -.........Attyfnplomafo:::: phasu (ClinkiLl LJ.lu,nc)·)--------1
PrimDry Acu1e HtV· Symplom.illt:
Stage Cunsl:ilnHorml
Jnfcclicm Syndrome All)S
Symp1nms

I F•g 3. ll) · D1,1grJ111m,,t1c R,c>p1e,ent,1t1011 of Ant,9011 ,rnd Antibody Response and CD� counts and PVL 111 HIV1nfect1on and AIDS

112
( 3 > Abdomen
Table 3.22 : Initial Evaluation
History Symptoms, past and present history (personal, high risk behavior, family history,
gynecological, treatment etc.)
Physical Examination Routine complete examination including dermatological, oral, genital, pelvic,
systemic, fundus, etc.
Hematology& Urinalysis Routine
Blood Chemistries Routine including LFT, BUN, creatinine, etc.
Lipid profile and glucose (fasting) To rule out existing CAD, diabetes prior to ART
HIV Antibody Confirm HIV·1 infection & rule out HIV-2 infection
CD4+ T lymphocyte count Baseline level by flow cytometry
HIV RNA levels (viral load) Baseline plasma vira 1 load (PVL)
HIV Resistance Testing For patients with HIV RNA > 1 ooo copies/mL
Chest X-ray To rule out TB & other infections
VDRL/TPHA To rule out syphilis
Pap Smear& pregnancy test To rule out cervical intraepithetial neoplasia & pregnancy prior to ART
Serology for hepatitis A, 8, C To rule out co-existing viral hepatitis
Mini-mental status examination Baseline study

(reverse transcriptase PCR), bDNA (branched gitis. It lasts 1-2 weeks and resolves spontaneously as
DNA) or nucleic acid sequence-based assays. the immune response to HIV develops. Most patients
These tests are useful for patients with a positive will then enter a phase of clinical latency, although
or indeterminate ELISA and an indeterminate occasional patients will experience progressive immu•
Western blot or in patients in whom serologic nologic and clinical deterioration. It can be identified
testing may be unreliable (such as those with by recent appearance of HIV antibody or by presence
hyp ogammaglobulinemia). of viral products with negative or weekly reactive HIV
6. Viral Isolation: HIV can be cultured from tissue, antibody.
peripheral blood cells or plasma.
Asymptomatic Infection
Monitoring of HIV Infection The length of time between infection and development
Measurement ofthe CD4+ Tlymphocytecount (flow ofdisease varies greatly, but the median is estimated to
cytometry) and level of plasma HIV RNA (plasma be 10 years. HIV disease with active viral replication
viral load or PVL) are important in the routine evalu­ usually progresses during this asymptomatic period
ation and monitoring of HIV-infected individuals. and CD4+ T-cell counts fall. The rate of disease pro­
They are measured at diagnosis and usually every 3-6 gression is directly correlated with plasma HIV RNA
months thereafter. levels. Patients with high levels of HIV RNA progress
to symptomatic disease faster than do those with low
Clinical Manifestationsof HIV Infection levels of HIV RNA.

Primary HIV Infection& Acute HIV Symptomatic Disease


Syndrome
A variety of constitutional symptoms, PGL, neurologi ·
It can be asymptomatic or associated with features of cal disease, secondary infectious diseases, secondary
an acute viral syndrome of variable severity ( 50-70% neoplasms or organ-specific disease can be seen in
of infected individuals) 3-6 weeks post-exposure. It is HIV-infected patients, either as primary manifesta·
characterized by fever, lymphadenopathy, arthralgias, tions of the HIV infection or as complications of
myalgias, maculopapular rash, urticaria, abdominal treatment (Refer to Table 3.30)
cramps, diarrhea, orogenital ulcers or aseptic menin-

113
PRACTICAL MEDICINE

Table 3.23: Immunizations Table 3.25 : ART Recommendations for


Recommended Adult or Adolescents
Vaccine/ lmmun ization Recommendation Patient group Preferred first line Preferred second
line regimen
Hemophilus influenza virus All patients: Single dose
as early as possible and Adult or NNRTl+2NRTI Boosted Pl+2 NRTI
annually adolescent
Streptococcus pneumoniae All patients: Single dose as Pregnancy with NVP +AZT+ 3TC Not applicable
early as possible HIV
Hepatitis B All susceptible patients (anti HIV with TB EFV+2NRTI Boosted Pl*+2
H Be and anti·HBs negative:3 NRTI
doses
Hepatitis B with TDF+ 3TC +NNRTI Boosted Pl+ 2 N RTI
Hepatitis A All susceptible (anti-HAV HIV
negative) patients or at risk:
Hepatitis C with EFV+2NRTI Boosted Pl + 2 NRTI
2doses
HIV
DPT (Diphtheria, Pertussis, All patients. Booster every
HIV·2 or dual 3 NRTI Boosted Pl+2 NRTI
tetanus) 10years
infection
IPV (Inactivated polio virus) AlI patients not previously
NNRTI = Non-nucleoside reverse transcrlptase Inhibitor;
vaccinated: 3 doses of
enhanced potency IPV NRTI= nucleoside/nucleotide reverse transcriptase inhibitor;
vaccine or oral polio vaccine Pl= Protease inhibitor; AZT Azidothymidine, Zidovudine;
iflPV not available EFV= Efavirenz;NVP = Nevi rapine; LPV.. Lopinavir /r booster
dose Ritonavir; RTV= Ritonavir; TDF Tenofovir; 3TC=
MMR* (Measles, mumps, All patients not previously Lamivudine; RMP= Rifampicin; RFB= Rifabutin.
rubella) vaccinated and booster to Boosted Pl = Pl boosted with Ritonavir
those immunized but with no
history of measles.
Table 3.26 : ART for Treatment-Na"jve
Typhoid, Cholera, Plague, To patients traveling to Patients (1-NNRTI + 2-NRTls)
Men ingococcus, Japanese endemic/ epidemic areas.
encephalitis, Hepatitis A Preferred NNRTI Efavirenz
Alternative NNRTI Nevirapine
Yellow fever, BCG, Live oral Not recommended
typhoid. Live oral polio Preferred Dual NRTI Tenofovir + Emtricitabine
Alternative Dual NRTI Abacavir+ Lamivudine
VariceIla Zoster immune Patients exposed to th is virus
Alternative Dual NRTI Zidovudine + Lamivudine
globulin
Immune Reconstitution Inflammatory
Table 3.24 : When to Start ART Syndrome (IRIS)
Antiretroviral therapy should be initiated in:
When a patient starts anti-retroviral therapy (ART),
1. Patients with a history of an AIDS-defining illness his immune deficiencies improve. This sometimes
2. Patients with a CD4 T-cell count <250 cells/µL or results in uncontrolled inflammatory responses. Hence
decreasing the patient may show worsening of clinical features
3. Following patients (regardless of CD4 cell count): or laboratory parameters in spite of improving CD4
a. Pregnant women
counts and decreasing viral loads.
b. Patients with HIV-associated nephropathy Manifestations of IRIS
(HIVAN), non-Hodgkin's lymphoma
l. Development of symptoms within 3 months of
c. Patients co infected with HBV/HCV when
treatment is indicated
starting ART.
d. Patients with HIV RNA (PVL) >50,000 copies/ml
2. Symptoms
or increasing a. Fever, wasting
e. Post Exposure Prophylaxis

114
< 3) Abdomen
Table 3.27 : Primary and Secondary Prophylaxis for prevention of Ols
Opportunistic Agent Indications for starting Drug & Dosage (First choice)
Mycobacteriumtuberculosis (TB) Tuberculin test >Smrn or high risk INH sensitive: INH 5 mg/kg/dayPO qds +
Or prior positive test without treatment pyridoxine 50 mg PO qdsx9 months
Pneumocystis cariniipneumonia CD4 < 200/mm3 or rapid clinical TMP/SMX 1 OS tablet PO qds
{PCP) deterioration or prior PCP Pentamidine aerosol 300 mg/month
Mycobacterium CD4 < 50/mm 3 Azithromycin 1200 mg PO weekly
avium-intracellulare (MAC) Or prior documented disease Or Clarithromycin
Toxop/asmagondii Positive lgG antibody and TMP/SMX 1 OS tablet PO qds
CD4<100/mm3
Herpes simplex Frequent/severe recurrences Acyclovir 200 mg PO tds or Famciclovir
250 mgPObds
Candida albicans, Crytococcosis CD4 < 200/mm3 Fluconazole 1 00-200 mg
Frequent/severe recurrences PO once/week

Table 3.28 : Evaluation and Management of the Drug Resistance


Evaluation Assessment of symptoms of HIV disease
Antiretroviral treatment history: Duration, drugs used, antiretroviraI potency, adherence history, an(J
drug intolerance/toxicity
HIV RNA and CD4 T-cell count trends over time
Results of prior drug resistance testing
Types:
a. Vlrologic failure HIV RNA level > 400 copies/ml in 24 weeks or > 50 copies/ml in 48 weeks or rising levels (after prior
suppression of viremia)
b. lmmunologicfailure Failure to achieve and maintain an adequateCD4 response despite virologic suppression
c.Clinical Failure Manifestation of AIDS in a patient on ART (usually assoc. with virological & immunological failure)
Drug resistance Genotypic or phenotypic testing carried out while the patient is taking the failing antiretroviral
testing regimen (patient should not stop treatment regimen)
Goals of treatment Re-establish maximal virologic suppression (HIV RNA <50 copies/ml)
Change individual antiretroviral drugs to reduce or manage toxicity, if any
Assess ad herenee frequently and simplify the regimen as much as possible
Antiretroviral Add at least 2 new (preferably 3)fully active agents to an optimized background antiretroviral
treatment (ART) reaimen deoendina on results of resistance testina

b. Tuberculous cold abscesses, pericardia!


effusion, pleural effusion, ascites
c. Hepatospenomegaly or lymphadenopathy
d. Pneumonitis/pneumonia
e. Increase in cerebral space-occupying lesions,
meningitis, encephalitis
Treatment of IRIS
I. Symptomatic treatment
2. NSAIDS
3. Severe IRIS: Prednisolone
4. Life-threatening IRIS: Stop ART

115
PRACTICAL MEDICINE

Management 3. Suppress PVL to undetectable levels ( <50 copies/


mL)
General principles 4. To prevent opportunistic infections
1. Multidisciplinary approach to reduce HIV­ 5. To manage side effects of ART
related morbidity and mortality and improve 6. To reduce HIV-related morbidity and prolong
quality of life. survival, improve quality of life and to prevent
2. Counseling, psychosocial support vertical HIV transmission
3. Education of the patient about HIV, AIDS, ART Drugs (Also Refer to Ch. 15)
transmission, risk of infections, neoplasms, etc.
4. Education of the general public, colleagues, Management of Symptomatic AIDS and
employers and hospital staff. Advanced Disease
1. Continue treatment with antiretroviral agentsas
Treatment of Constitutional Symptoms
per Tables above. Ensure compliance.
1. Fever: Intermittent or long-term use of non­
2. Continue treatment of symptomatic complaints.
steroidal anti-inflammatory drugs.
3. Patients with symptomatic disease pass from
2. Night sweats: Regular use of antipyretic agents
the stage of late moderate symptoms and
since there is associated fever.
immune function deterioration to one or more
3. Chronic diarrhea: Symptomatic treatment opportunistic life threatening manifestation and
(till no specific pathogen identified) with more severe immune dysfunction. There is an
Loperamide, Diphenoxylate HCl/Atropine increasing risk of mortality as CD4+ counts fallto
sulphate, Somatostatin. <50 cells/µL. These patients need more frequent
4. Fatigue: Evaluate for thyroid or adrenal clinical examination, diagnosis and immediate
insufficiency, neuropathy, myopathy and treatment.
depression and treat if detected. 4. Various systems are affected throughout the
5. Minor oral infections: Oral hairy leukoplakia course of HIV infection and may be the direct
needs no treatment unless severe ( oral acyclovir). result of HIV infection, manifestation of
Periodontal disease is treated with chlorhexidine. Table 3.29 : Recommended PEP
6. Headache: Symptomatic treatment with non­ Exposure Low Risk• High risk"
steroidal anti-inflammatory agents preferred Source HIV Source HIV
to narcotics. Specific pathogen to be identified Negative Positive

and treated. Less Severe 2 drug PEP 3 drug PEP


(Solid needle, superficial injury)
7. Nutritionaldeficiencies(e.g. iron, Vitamin B 12)
to be corrected, if present. More Severe 3 drug PEP 3 drug PEP
(Large bore hollow needle,
Antiretroviral Therapy (ART) deep puncture, visible blood
on device or needle used in
The cornerstone of medical management of HIV patients' artery or vein)
infection is antiretroviral therapy (ART) since it sup­ Post Exposure Prophylaxis
presses HIV replication. The drugs that are currently
Low risk, HIV +ve low risk source· Arr+ 3TC (2 TDF + 3TC
licensed for the treatment of HIV infections are listed &less severe exposure drug PEP)
in Chapter 15.
High risk, HIV +ve high-risk All+ 3TC + AZT+ 3TC
Goals of Management ofART source&anytype ofexposure LPV /r(3 + EFV
drug PEP)
l. Avoid transmission of HIV 'Low risk: Asymptomatic or viral load< 1500 copies/ml
2. Maintain CD4+ counts> 350cells/µL ..High risk: Symptomatic HIV, AIDS, acute seroconversionand/
or high viralload

116
( 3 > Abdomen
opportunistic infections and neoplasms, or side remain the cornerstone of HIV prevention efforts.
effects of ART(Refer to Table 3.30). While abstinence is an absolute way to prevent sexual
transmission, other strategies include 'safe sex practices
Post Exposure Prophylaxis (PEP) such as use of condoms together with the spermatocide
Antiretroviral drugsfor PEP should be started within nonoxynol-9. Avoidance of shared needle use by ID Us
the first few hours and no later than 72 hours after is critical. If possible, HIV-positive women should
occupational and non-occupational exposureand avoid breast-feeding (in India breast-feeding is benefi­
continued for 28 days (See Table). HIV testing should cial and mixed feeding is absolutely contraindicated)
be done initially and following 3 and 6 months. as the virus can be transmitted to infants via this route.
Prevention of exposure is the best strategy and stresses
Prevention the use of universal precautions and proper handling
Education, counseling, and behavior modification of needles and other potentially contaminated objects.
Table 3.30: Complications in HIV infection and AIDS - Features, Diagnosis and
Treatment
System Fear urns Diagnosis Treatment

RESPIRATORY SYSTEM
Upper Respiratory Tract Acute bronchitis, sinusitis, CT/MRI Antimicrobial agents
Infection (URTIJ fever, nasal congestion,
S.pneumoniae, H.influenzae headache
Pneumonia Pneumonia, sinusitis, X-ray Antimicrobial agents
S.pneumoniae, H.influenzae bacteremia
Pneumocystis pneumonia Fever, cough,dyspnea, night X-ray; Demonstration of Trimethoprim/
(PCP) P.jiroveci (carinii) sweats, thrush, unexplained organism in sputum, BAL, sulphamehtoxazole DS 2
weight loss transbronchial or open lung tablets PO for 21 days followed
biopsy by secondary prophylaxis
Tuberculosis: M. tuberculosis Cough, hemoptysis, shortness Positive sputum smear or Anti-tuberculosis treatment:
of breath, chest pain, weight X-ray showing TB Standard 4-drug regimen for
loss, fever, night sweats 6-9 months. For TB involving
CNS: 12 months.
Atypical Mycobacterlal Weight loss, fever, night Organisms in blood,sputum or Clarithromycin 500 mg PO
infections M.avium, sweats; Dissemination to bone involved tissue; X-ray ql 2h + Ethambutol 15 mg/kg
M.intracel/ulare (MAC) marrow, lung, liver, lymph PO q24h;
nodes Can add rifabutin,
ciprofloxacin or amikacin
Fungal infections of the lung Fever, cough, dyspnea, Chest X-ray, sputum Anti-fungal agents
Cryptococcus, Coccidioides hemoptysis examination
immitis, Aspergillus,
Histoplasmosis
Kaposi's Sarcoma (KS) Purplish vascular nodules on Biopsy of suspected lesion; Optimal ART & observation;
skin, mucous membranes, Chest X-ray
viscera
Single or Iimited lesions Radiotherapy, 1ntra1esional
vinblastine. cryotherapy
Extensive disease Interferon- a, liposomal
daunorubicin
Lymphomas: lmmunoblastic, Fever, seizures, mass lesions in MRI, CT scan Combination
Burkitt's, Primary CNS oral mucosa chemotherapy,steroid s.
lymphomas radiotherapy

117
PRACTICAL MEDICINE

Syst,rm Features Diagnosis Treatment

CARDIOVASCULAR SYSTEM
HIV-associated Edema, dyspnea, dilated Chest X-ray, ECG. Echo ART, treatment for heart
cardiomyopathy cardiomyopathy with failure, IV lmmunoglobulin
congestive heart failure
Pericardia! Effusion Asymptomatic or chest pain, Echo, pericardia! fluid culture Treat underlying condition,
dyspnea, cardiac tamponade, and cytology start ART if idiopathic, NSAIDS,
pericardia! friction rub steroids.
Pericardiocentesis if
tamponade is present
Non-bacterial thrombotic Fever, weight loss, Heart murmur, Chest X-ray, Antimicrobial therapy
endocardltis unexplained embolic Echo, blood culture according to isolated organism
phenomena
GASTROINTESTINAL SYSTEM
Oropharynx: Dysphagia/odynophagia Pseudomembrane, Candida: Fluconazole 100 mg
Thrush (Candida) examination of scraping POq24h
Hairy leukoplakia (EBV) EBV: Topical podophyllin or
Aphthous ulcers anti-herpes virus agents.
Aphthous ulcers: Topical
anesthetic, thalidomide
Esophagus: Esophagitis Odynophagia, retrosterna I Upper endoscopy Systemic therapy as indicated
(CMV, HSV, Candida); pain
Neoplasm (KS, lymphoma)
Stomach: Ach lorhydria, Ach lorhydria: Gastric Gastric pH at endoscopy Stop ART drug, if cause.
Kaposi's sarcoma, Lymphoma discomfort Treat underlying condition.
Obstructive jaundice
Intestine: Infections due to: Fever, anorexia, fatigue, Stool and blood examination Treat underlying infection as
Bacteria (S.typhimurium, malaise, diarrhea & culture, Endoscopy with per diagnosis
Shigella, Campylobacter. biopsy
S.typhi, S.flexneri)
Fungi (Histoplasmosis,
Coccidioidomycosis,
Penicilliosis)
Parasites (Cryptosporidia,
Microsporidia, lsospora be/11)
Viruses (CMV colitis)

Rectal: Infections (HSV), Peri rectal ulcers. erosions Examination Treat underlying condition as
neoplams (KS) per diagnosis
AIDS Enteropathy Chronic diarrhea, weight loss Histology of small bowel Treat underlying condition as
per diagnosis
HEPATOBILIARY SYSTEM
HepatitisB Asymptomatic or symptoms HBAAb, HBSAg, HBCAb&in Enticavir + pegylated
of hepatitis, elevated I iver chronic cases HBEAg, HBEAb interferon.
enzymes & HBV DNA levels, imaging ART Combination Therapy
Hepatitis A vaccine if non-
immune.
Hepatltis C Asymptomatic, elevated liver HCV Antibody or HCV RNA Pegylated interferon +
enzymes positivem, imaging Ribavirin (C/1 in pregnancy).
Hepatitis A & B vaccine if non·
immune.

us
< 3) Abdomen
system Features Diagnosis Treatment

Granulomatous hepatitis, Asymptomatic or symptoms Liver enzymes elevated, liver If ART-induced, stop offending
hepatic masses, biliary tract of hepatitis,elevated liver biopsy, imaging drug.
disease, Hepatitis G virus enzymes

ENDOCRINE SYSTEM

Lipodystrophy Truncal obesity, peripheral Increased plasma Gemfibrozil, atorvastatin


wasting or1ipoatrophy triglycerides, total cholesterol,
apolipoproteinB, insulin,
glucose

Avascular necrosis Hip or shoulder pain Osteonecrosis on MRI Stop offending drug, if any

Lactic acidosis Stop offending drug, if any

Hyponatremia {SIADH), Symptoms of condition Serum sodium,thyroid Stop offending drug,if any.
hypothyroidism, function tests Treat underlying condition as
hyperthyroidism per diagnosis

RENAL AND GENITOURINARY SYSTEM

HIV-associated nephropathy Asymptomatic to symptoms Proteinuria, ultrasound, ART; ACE inhibitors and/or
{HIVAN) of renal failure biopsy prednisone60 mg/d for 1
month, then taper

Genitourinary tract Skin lesions,dysuria, Clinical and Urine Examination Treat underlying condition as
infections (e.g. HSV, syphilis, hematuria and/or pyuria, per diagnosis
candidiasis) vaginal discharge, etc.

RHEUMATOLOGICAL DISEASES

Immune Reconstitution Refer Pg.114


Inflammatory syndromes
{IRISI

Arthritis - reactive Pain in joints. Arthrocentesis with culture, NSAIDs, pain relievers
{Psoriatic, septic) Urethritis, skin lesions & gram stain, urethral swab for Methotrexate causes
Conjunctivitis {gastroenteritis) Chlamydia and gonorrhea, increased 01, used only in
HLAB27 severe cases

AIDS-associated Painful non-erosive MRI NSA1Ds and pain relievers


arthropathy arthropathy in multiple joints
(knees, ankles)

Polymyositis Musculoskeletal pain for >3 Clinical examination & biopsy Low dose naltrexone
months at multiple sites of muscle, EMG

HEMATOPOIETIC SYSTEM

Anemia, neutropenia, Signs of Mild or severe anemia CBC, red cell indices,retie Anemia: Blood transfusions;
thrombocytopenia (ITP, TTP) or neutropenia, bleeding in count, serum iron, Bl 2, folate iron if IDA, erythropoietin;
severe ITP studies avoid drug, if drug-induced;
Neutropenia: G-CSF if ANC
<750/mm'
/TP:ART

Lymphadenopathy Inguinal Site Biopsy of lymph node or bone ART


marrow in patients with CD4+
<200/pl

Persistent Generalized Enlarged lymph nodes > 1 cm; Clinica I examination No treatment
lymphadenopathy (PGL) In 2 or more extra-inguinal
sites for>3 months with no
obvious cause

119
PRACTICAL MEDICINE

System featurt!i Diagnosis Treatment


DERMATOLOGICAL DISEASES

Seborrheic dermatitis Waxy erythematosus plaques Clinical appearance ART, ketoconazole cream,
usually on face and scalp topical steroid
Eosinoph i lie pustular Multiple erythematous, Skin biopsy ART, corticosteroids,
folliculitis papular, severely pruritic isotretinoin, phototherapy
eruptions on upper trunk, face
Psoriasis& lchthyosls May be preexisting condition Clinical examination ART, standard therapy
Reactivation herpes :z:oster Shingles- may be multi· Clinical examination, Acyclovir, Famciclovir
dermatomal immunofluorescence to
distinguish from HSV
Herpessimplexvirus (HSVJ Skin & recurrent oral/ Viral culture ofHSV Acyclovir, Famciclovir
anogenital lesions
Molluscum contagiosum White, u mbilicated, Clinical appearance ART
diffuseskin eruptions in groin
Condyloma acuminatum Extensive vegetating lesions Clinical appearance; ART; Surgery, cryotherapy
in perianal or oral area due to Histopathology
human papilloma virus
NEUROLOGICAL DISEASES

Opportunistic infections Toxoplasma: Fever, Cryptococcus: CSF India ink Toxop/asma: Sulfadiazine
(Toxoplasmosis, headachace, focal examination. & pyrimethamine with
Cryptococcosis, neurological deficits, ocular Detection of antigen in serum, leucovorin for 4-6 wks. And
cytomegalovlrus, TB) disease CSF, tissues; prophylaxis.
Crytococcus: Meningitis. MRI/CT; T. gondilgG antibodies Crytpococcus: IV amphotericin
May also have pulmonary in serum B 0.7 mg/kg daily with
disease. flucytosine 25 mg/kg qid for 2
CMV: Encephalitis, wksfollowed byfluconazole
polyradicu litis, 400 mg/day PO for 1 O wks
and 200 mg/day PO till CD4
+ count > 200 cells/µl for 6
months CMV: Gancydovir
5 mg/kg IV BDS + lifelong
Valganciclovir 900 mg PO OD
Neoplasms {primary CNS Focal neurological deficit or MRI/CT, SPECT, PET scan, EBV ART
lymphoma) seizures, fever, DNA Steroids and radiotherapy
Definitive diagnosis-
stereotactic brain biopsy
Aseptic meningitis Headache, photophobia, CSF examination Usually resolves
meningismus spontaneously
HIV Encephalopathy {AIDS StageO to 4: mild to severe CSF examination; MRI/CT; HIV ART with drugs which
dementia complex) neurological symptoms (HIV- RNA inCSF; penetrate the CSF Ii ke AZT,
associated neurocognitive MMSE (mini-mental status ABC,d4T. NVP. IDV
impairment (HCNI)) examination)
Myelopathy or spinal cord Vacuolar myelopathy or pure CSF examination
disease sensory ataxia; dementia
Peripheral neuropathy (HIV/ Pain, aching, burning, or Clinical, EMG Withdraw offending drug.
Drug-induced) tingling at distal extremities Continue ART. Symptomatic
treatment

120
� 3, Abdomen

System Features Diagnosis Treatment

Progressive multifocal Multifocal neurologic deficits JC virus DNA levels in CSF; ART
leukoencephalopathy with or without changes in MRI
(PML), mental status
OPHTHALMOLOGIC DISEASES

CMV retinitis Painless, progressive loss of Ophthalmological exam; Ganciclovi r intraocular implant
vision Differentiate from benign + valgancilovir for 21 days
"cotton-wool spots" fol lowed by maintenance dose

GENERALISED WASTl NG Involuntary weight loss> 10% Clinical examination Steroids, given with caution
SYNDROME with fever, chronic diarrhea or due toOI
fatigue lasting > 30 days. Androgenic hormones, growth
hormones, total parenteral
nutrition
NEOPLASTIC DISEASES
Kaposi's sarcoma, Non-Hodgkin's lymphoma, Primary CNSlymphoma, Cervical/anal cancer (see above)

121
1 > Proforma VIII. Mediastinal compression:
A. Dysphagia
History B. Hoarse voice
I. Cardinal symptoms: C. Dyspnea and dry cough
A. Cough D. Swelling over face
B. Expectoration General Examination
C. Hemoptysis
I. Built and nutrition
D. Breathlessness
IL Nails and conjunctiva: Pallor, dubbing, cyanosis,
E. Wheeze icterus
F. Chest pain Ill. lymphadenopathy (especially scalene node
IL History of tuberculosis: and cervical nodes), edema of feet, JVP
A. Evening rise of temperature, night sweats IV. TPR, BP
B. Anorexia and weight loss V. Spine
C. Hemoptysis VI. Stigma of tuberculosis:
D. Pleurisy, meningitis, lymphadenitis in past A. Phlyctenular conjunctivitis
or in family, TB contact B. Scars and sinuses in neck or bones
Ill. Habits: Alcohol, smoking, tobacco or gutka C. Thickened spermatic cord
chewing D. Erythema nodosum
IV. Aspiration: Foreign bodies, vomitus.
E. Skin: Cutis vulgaris, scrofuloderma etc.
V. For Industrial diseases: Occupation, residence
VII. Neck: Thyroid swelling. Tracheal tug
near factories or mills
VIII. Homer's syndrome: Ptosis, miosis, anhydrosis,
VI. Allergy:
enophthalmos and absent ciliospinal reflex
A. Family history of asthma, hay fever, eczema
IX. Upper respiratory tract:
B. Rhinitis and Sinusitis: Nasal discharge, pain
A. Sinus tenderness
and tenderness over sinuses, headache,
recurrent cold B. Throat and tonsils
VII. Past history: C. Posterior pharyngeal wall for posterior
nasal drip
A. Measles, influenza or whooping cough in
childhood (If bronchiectasis) D. Alae nasi
B. Diabetes X. Gums and teeth
C. Exposure to TB, STD, HIV
( 4 ) Respiratory System

Respiratory System Examination Ill. Percussion:


I. Inspection: A. Anteriorly
Rig/rt Side Left Side
A. Shape of chest 1. Kronig's isthmus Kronig's isthmus.
l. AP and transverse diameters: Barrel 2. Clavicular percussion Clavicular percussion
shaped chest, etc. 3. Intercostal resonance Intercostal resonance
2. Hollowing, bulging, flattening or 4. Liver dullness Cardiac dullness
5. Tidal percussion Traube's area
retraction
6. Shifting dullness Shifting dullness
3. Sub-costal angle 7. Percussion myokymia Percussion myokymia
4. Shoulders 8. Skodaic resonance Skodaic resonance
5. Spine B. Posteriorly
6. Spinoscapular distance on both sides l. Supra-scapular
B. Respiratory Movements 2. Inter-scapular
1. Respiratory rate 3. Infra-scapular
2. Rhythm C. In Axilla
3. Character - Abdominal, thoracic, l. Axillary
thoraco-abdominal or abdomino­ 2. Infra axillary
thoracic
IV. Auscultation:
4. Equality
A. Breath Sounds
5. Accessory muscles of respiration
l. Normal or Diminished
6. Inter-costal retraction I fullness
2. Type: Vesicular, bronchial or vesicular
C. Mediastinum with prolonged expiration
1. Trailes sign B. Foreign Sounds: Rales, rhonchi or rub
2. Apex impulse C. Vocal Resonance
D. Miscellaneous D. Miscellaneous
l. Scars, sinuses l. Bronchophony
2. Pulsations 2. Egophony
3. Dilated veins 3. Whisperin g pectoriloquy
4. Shinyskin overlowerchest (Empyema, 4. Succussion splash
hepatic amebiasis)
5. Coin test
II. Palpation
6. Post-tussive suction
A. Findings ofinspection confirmed including
Chest Movements 7. Post-tussive rales
B. Mediastinum Final Diagnosis
l. Trachea l. Anatomy (Where is the lesion?) e.g. Right upper
2. Apexbeat lobe
C. TACTILE VOCAL FREMITUS: TVF 2. Pathology (What is the lesion?) e.g. pneumonia
D. Miscellaneous 3. Etiology (What is the cause?) e.g. streptococci
Tenderness over lower inter costal spaces. 4. Complications e.g. lung abscess
Other vibrations: Palpable rates, rhonchi, 5. Risk factors e.g. smoking
rub

123
PRACTICAL MEDICINE

2 Examination is unduly prominent and the cross-section


is triangular.
A: Inspection and Palpation

2. Funnel chest (Cobbler's chest or pectus


excavatum): There is a depression in the
I. Shape of the Chest lower part of the sternum which may be
Normally the chest is bilaterally symmetrical, congenital, following rickets in childhood
with smooth contours, and slight recession below or an occupational deformity in cobblers.
the clavicles. On cross-section, it is ellipsoidal Due to the sternal depression, the normal
in shape, its anteroposterior diameter is lesser cardiac shadow may appear enlarged on
than its transverse diameter with a ratio of 5:7. X-ray chest (Pomfret's heart).

,---- - -- ­
The subcostal angle is acute, about 70° and
the interspaces are broader anteriorly than
posteriorly.

!
. Fig.4.4. Funnel chest (Sternal depression]

3. Barrel shaped chest: The anteroposterior


diameter is increased, the sub-costal angle is
wide, the angle of Louis unduly prominent,
the sternum is more arched, the spine is
Abttormal Shapes of the Che.st
I. Rickets (pigeon breast or keeled chest or
pectus carinatum): There is depression
on either side of the sternum often
associated with bead like enlargement at the
---
costochondraljunction (rickety rosary) and
a transverse groove passing outwards from
the xiphisternum to the mid-axillary line
(Harrison's sulcus). Sometimes, the sternum

124
{ 4 ) Respiratory System

unduly concave forwards and the ribs are A. Increased respiratory rate (tachypnea)
less oblique. This is seen in emphysema, old I. Exertion and excitement.
age and infancy. The Ratio of AP diameter
2. Fevers e.g. pneumonias
to transverse diameter is normally 5:7. In
the barrel-shaped chest it is l: l or more. 3. Anoxemia and acidosis
4. Spinal deformities: Kyphosis or scoliosis 4. Anemia and poisoning
(Ch. I) due to any cause may lead to 5. Pain whilst breathing e.g. pleurisy
asymmetry and may decrease the size of the B. Decreased respiratory rate (bradypnea)
thoracic cage and restrict lung movements

I
1. Narcotic poisoning e.g. opium
and volume.
2. Brain tumour
C. Dyspnea: Breathlessness
Table 4.1 : Dyspnea: American Thoracic
Society (ATS) Scale
Grade Degree Description

0 None Not troubled by shortness of breath


on level or uphill

Mild Troubled by shortness of breath on


Fig.4 6 Chestwa'I appearance with Kyphosco.ios1s level or uphill

5. Bulging: One side may bulge in pleural 2 Moderate Walks slower than persons of same
effusion,pneumothorax, tumors,aneurysm, age
empyema necessitans, cardiomegaly or 3 Severe Stops after walking 100 yds or after
scoliosis. Localized bulging is seen in few minutes on level ground
aortic aneurysm, pericardia! effusion, liver 4 Very Severe Too breathless to leave the house or
abscess, chest wall tumors etc. breathless on dressing or undressing

6. Depression or flattening: One side of the Table 4.2 : Dyspnea: Modified Medical
chest or a part of it may be depressed Research Council (MMRC) Scale
or flattened in fibrosis, collapse, pleural
Grade Description
adhesions, unilateral muscle wasting due
to poliomyelitis or congenital absence of Breathlessness only with strenuous exercise
pectoralis muscles. 2 Breathless when hurrying on level or walking
7. Flat chest (phthinoid chest): The uphill

anteroposterior diameter is reduced in 3 Walks slower than persons of same age


chronic nasal obstruction due to adenoid 4 Stops after walking 100 yards or after few minutes
lymphoid hypertrophy, bilateral TB or on level ground
childhood rickets. In advanced TB, the 5 Too breathless to leave the house or breathless on
scapula is winged and is called Alar chest. dressing or undressing
AP: Transverse Diameter Ratio is 1:2 or
less. Ill. Respiratory Rhythm

II. Respiratory Rate The normal respiration has regular rhythm with
inspiration longer than expiration. Irregular
The normal rate in adults is 16 20 respirations respiration may be of the following types:
per minute {in children about 40 per min.) It
A. Cheyne-Stokes Respiration: This consists
bears a definite ratio with the pulse rate of about
of rhythmical alteration of apnea and
1:4.
hyperpnea due to anoxemia. Anoxemia

125
PRACTICAL MEDICINE

abolishes spontaneous rhythmic activity


ofbreathing. Consequent apnea results in
accumulation of CO2 in the body, thereby
stimulating the respiratory centre and
causing hyperventilation. This causes Fig 4 1 O Apneusticresp1rat1on

CO2 washout and results in depression of E. Stridor: This is characterized by prolonged


respiratory centre and apnea and thus the inspiration through an obstructed upper
cycle continues. airway, which produces a characteristic
Causes: sound.
l. Left ventricular failure Causes:
2. Increased intra cranial pressure with l. Laryngeal or tracheal obstruction
damage to both cerebral hemisphere 2. Laryngeal diphtheria
and diencephalon. 3. Mediastinal growth
3. Na rcoti c p o i s o ning: o piu m, F. Wheezing: This is characterized by
barbiturates etc. prolonged expiration th roughan obstructed
4. Uremia lower air way,bronchi, bronchioles, etc. This
5. Deep sleep can also occur in cardiac and renal asthma.
Table 4.3 : Differences between Stridor
and Wheeze
Stridor Wheeze
F,g 4 ?·Cheyne Stokes Resp1rat1on
lnspiratory Expiratory
B. Ku s smaul's respir ation: This is
characterized by deep and rapid respiration Upper Airway Lower Airway

(air-hunger) and is seen in diabetic Cause: Foreign body Cause: Asthma


ketoacidosis, alcoholic or star vation
ketoacidosis and in uremia. F. Stertor: Stertorous breathing occurs in
coma or deep sleep or in dying patients
(death rattle - rattling noise in throat).
IV. Type of Breathing
Fig.4 8 Kussmaul'sresp1rat1on The normal breathing in males and some females
C. Biot'srespiration (chaotic breathing): This is abdominothoracic i.e. both the abdomen and
is irregularly irregular respiration seen in thorax are moving during the act of respiration
meningitis or raised intracranial pressure. but the abdominal movements are more
prominent. The normal breathing in majority
offemales is thoracoabdominal i.e. the thoracic
movements are more prominent than abdominal
movements:
l. Thorade breathing:Thethoracicmovements
Fig.4.9 B1ot's resp1rat1on
are predominant and abdominal movements
are minimal. It occurs with diaphragmatic
D. Apneustic respiration : It is characterized paralysis, peritonitis and severe ascites.
by full inspiration followed by a pause, 2. Abdominal breathing: The abdominal
alternating with full expiration followed movements are predominant and thoracic
by a pause. Each pause is 2-3 seconds. It is movements are minimal. It occurs in
seen in pontine lesions. pleurisy and collapse of the lung.

126
( 4 Respiratory System

v. Movements of the Chest VI_ Mediostinum


Normally both the sides of the chest wall move The med iastinum is normally central. The shift of
uniformly and there is no bulging, or indrawing the mediastinum can be detected by noting the
of the interspaces. Accessory muscles of position oftrachea and apex beat. On inspection,
respiration are usually not required for the act sternocleidomastoid becomes more prominent
of breathing. on side to which trachea is shifted. This is Trail
Normally, on taking a deep breadth, the chest Sign.
circumference (measured at the level of the
nipple) increases by 2 inches.
A. Unilateral diminished movements
I. Obstruction to the main bronchus
2. Consolidation
3. Fibrosis of the lung and pleural
adhesions
4. Massive collapse
5. Hydropneumothorax
6. Pleural Effusion
B. Bilateral diminished movements The trachea is examined by inserting finger
I. Emphysema upward in the suprasternal notch and noting
its relation to the two sternomastoid muscles.
2. Bilateral fibrosis, collapse, consolida­ Normally the trachea may be shifted slightly to
tion or hydropneumothorax the right or is central.
3. Bronchial asthma The apex beat is examined with the palm of the
The accessory muscles of respiration, alae nasi hand and its position is noted. Normally the
and sternomastoid are normally not required for apex beat is in the fifth left intercostal space just
respiration. However in any conditions that cause inside the mid-clavicular line. It may be shifted
respiratory embarrassment, they are required to inward or outward depending upon the shift of
assist breathing and may therefore be prominent. the mediastinum.

127
PRACTICAL MEDICINE

frequency as the lungs and the chest wall. The


fundamental frequency of female voice is often
higher than that of the lungs, therefore TVF may
be markedly diminished or absent in women. In
children, although the fundamental frequency
is high, TVF can be appreciated because it
corresponds to the fundamental frequency of
the small lungs.

Significance
I. TVF is increased in
1. Consolidation which may be due to
pyogenic or tuberculous infections
The position of mediastinum in various
respiratory diseases is given in the table. 2. Following pulmonary infarction
The apex beat alone may be shifted in scoliosis, 3. Surrounding a malignant lesion
funnel shaped depression of the sternum and superficial cavity.
with cardiac disease. II. TVF is decreased in
Table 4.4 : Position of Mediastinum in A. Pleural diseases:
Respiratory Diseases 1. Pleural effusion
Central Shifted to Shifted to opposite side 2. Pneumothorax
same side (Push)
(Pull) 3. Hydropneumothorax
1. Bronchitis 1. Collapse 1. Pleural B. Bronchial diseases:
effusion
1. Bronchial obstruction
2. Bronchial 2. Fibrosis 2. Pneumothorax
asthma C. Lung diseases:
3. Bronchiectasis 3. Pleural 3. Hydropneumothorax 1. Emphysema
thicken-
ing 2. Pulmonary fibrosis
4. Emphysema 3. Pulmonary collapse
5. Pneumonia
6. Lung abscess
7. Interstitial
fibrosis

VII. Tactile Vocal Fremitus (TVF):


Definition
TVF is the tactile perception of vibrations
communicated to the chest wall from the larynx
via the bronchi and lungs during the act of
Fig 4. 14 ·Tactile Vocal Frem1tus
phonation.
Mechanism VIII. Other Vibrations
TVF occurs when sound vibrations from the Normally when the patient breathes, the
larynx pass down the bronchi and cause the palpating hand does not feel any vibrations.
lungs and the chest wall to vibrate. However, the However, vibrations may be felt in some diseases
spoken tones must have the same fundamental as follows:
1. Pleural Friction Rub: This occurs initially

128
( 4 J Respiratory System
in pleurisy due to rubbing ofthe two pleural
surfaces. It is usually felt at the peak of
inspiration or early expiration.
2. Bronchial Fremitus: This occurs in
bronchitis, bronchial asthma and chronic
obstructive lung disease.
3. Palpable Rale s: Thi s o ccurs i n
bronchiectasis, pulmonary fibrosis and
pulmonary congestion.

IX. Tenderness
Tenderness over the chest wall may be present
in local injury, myositis, amebic abscess ofliver,
F,g. 4.16:Clav,cular Percussion
pyogenic abscess ofliver and empyema.
of resonance or displaying extreme dullness is a stony
B : Percussion dull note. It is classically encountered over a pleural
The normal percussion note of the chest is due to the effusion, because fluid dampens the vibration of both
underlying lung tissue, containing normal amount of the chest wall and the underlying relaxed lung. It may
air in the air vesicles, air sacs and air passages. It has also occur in lung fibrosis with pleural thickening or
a distinctive and clear character with low pitch. The with solid intrathoracic tumour.
front of the chest yields a more resonant note than Tympany: This is a drum like resonance, which is
the back, because of the lesser bulk ofmusculature in normally encountered over the stomach, intestines,
front than at the back. larynx and trachea. When it occurs over the chest
Impaired note: When the amount of air in the alveoli wall it may be due to:
decreases, as in consolidation, infiltration, fibrosis and l. Pneumothorax
collapse ofthe lung, the lung fails to vibrate sufficiently 2. Superficial empty cavity
to the percussion stroke. This causes loss ofresonance
resulting in an impaired note. 3. Emphysema
Dull-note: An impaired note ofgreater degree is a dull Sub tympany {Skodaic resonance): A hyperreso-nant
note. In addition to consolidation, infiltration, fibrosis note with a boxy quality, which occurs due to the
and collapse oflung, it is found in pleural thickening. relaxed lung just above the level of pleural effusion.
Stony dull note: A percussion note completely devoid Hyper-resonance: A note in between in pitch between
normal resonance and tympany can be elicited over
the normal lung tissue by keeping the chest wall in full
inspiration, during percussion. It occurs in:
l. Pneumothorax
2. Emphysema
3. Large cavity with a thin wall
4. Congenital lung cyst
5. Emphysematous bullae
6. Eventration of diaphragm
Bell tympany: "Inis is a high pitched tympanic or
metallic sound, heard over the chest in case of massive
pneumothorax. When a silver coin is placed on the
F,g 4 15 Percusso1n of Chest affected side and percussed with a second silver coin,

129
PRACTICAL MEDICINE

the ear or stethoscope applied over the opposite side of dullness on the right side anteriorly, on
the chest may detect a clear bell like sound resembling inspiration and expiration serves to determine
the sound of"hammer on an anvil''. the range of lung expansion and movement of
diaphram. It is restricted in :
I. Kronig's Isthmus
1. Pulmonary diseases at lung base e.g.
Definition: Kronig's isthmus is a band of pulmonary fibrosis
resonance 5-7 ems in width, connecting lung 2. Empyema
resonance over the anterior and posterior aspects
3. Hepatic amebiasis
of each side of the chest. It is bounded medially
by dullness of the neck muscles and laterally by 4. Sub-diaphragmatic abscess.
dullness of the shoulder muscles. 5. Diaphram palsy
Abnormalities:
V. Traube's Area OR Space
l. Absence on either side suggests pulmonary
fibrosis due to tuberculosis. It is bounded above by the lung resonance, below
by the costal margins, on the right by the left
2. Increased width of resonance suggests
border of liver and on the left by spleen.
emphysema.
It is normally occupied by the stomach, hence on
II. Liver Dullness and Span percussion the note is tympanic due to stomach
gas. IfTraube's area is dull it suggests:
Normal liver dullness is in the right intercostal
space, in the fifth space in the mid-davicular I. Pleural effusion on the left side.
line, in the seventh space in the anterior axillary 2. Splenomegaly
line and in the ninth space in the scapular line. 3. Fundic tumor
Liver dullness may be present in the fourth space 4. Full stomach
in the mid-davicular line in amebic or pyogenic
abscess of the liver, diaphragmatic paralysis or VI. Shifting Dullness
collapse of the lower lobe of the lung. In case ofhydropneumothorax in sitting position
It may be pushed down to the sixth space in the there is a hyp erresonant note above followed
mid-clavicular line in emphysema, right-sided by dullness below. On changing the posture to
pneumothorax, air in the peritoneal cavity and supine, this area ofdullness of the fluid changes
terminal cirrhosis. as air and fluid will shift. This is shifting dullness
and always signifies presence of both air and
Ill. Cardiac Dullness
fluid.
On the left side of the chest wall, the lung
resonance is encroached by an area of cardiac VII. Coin-test
dullness due to the presence of the heart. The A coin is placed flat on the chest and struck
cardiac dullness is normally in the third and with another coin. On auscultation of the back
fourth left parasternal line and the fifth left mid of the chest on the same side, a metallic or bell
davicular line. like sound is heard.
This area of dullness may be decreased in Cause: Pneumothorax
emphysema, and left sided pneumothorax. It
may be increased with cardiomegaly and push VII. Percussion Myokymia
of the heart to the left side. In a chronically wasted individual as in
IV. Tidal Percussion pulmonary tuberculosis, a percussion stroke over
the front of the chest, dose to the sternum, may
Percussion of the upper border of the liver cause a transient twitchingofthemusdes, which

130
( 4 ) Respiratory System
type of breathing, presence of any foreign sounds and
vocal resonance.
The stethoscope should be firm!y placed over the chest
to prevent sounds resulting from the movement of the
chest. Hair on the chest wall may produce a crackling
sound and may be mistaken as rates. A similar sound
may occur in nervous patient due to shivering.

I. Breath Sounds
1. Vesicular: This is characterized by active
inspiration due to the passage of air into
the bronchi and alveoli followed without
a pause by passive expiration due to the
elastic recoil of the alveoli which occurs
maximally in the early phases giving an
apparent impression of short expiration.
is more marked on the side of the pulmonary
The character of the sound is rustling due
affection. This is called percussion myokymia.
to the passage through the alveoli which
Limitations ofpercussion selectively transmits lower frequency
sounds and dampens the high frequency
1. It is not possible to percuss deeper than 5 cm. sounds. It is normally heard over the chest.
Hence it is not possible to detect a lung lesion
The normal breath sounds are vesicularand
covered by a layer of air more than 5 cm thick
not bronchial because the lungs and chest
or fluid 1 cm thick.
wall act as an acoustic filter narrowing the
2. A lesion less than 2 cm in diameter does not range of audible frequencies to 100-400 Hz.
cause any change in the percussion note.
2. Bronchial: This is characterized by active
3. Free fluid less than 200 ml in the pleural cavity inspiration due to the passage of air into
may not be detected on percussion. the bronchi. The alveolar phase is absent

C: Auscultation (because of consolidation in alveoli) and


hence expiration is also active, occupying
Auscultation of the chest must be done to note the the same duration of time as inspiration.
Since the alveolar phase is absent there
is no rustling quality to the sound but a
hollow bronchial character because now
both lower and higher frequency sounds
are conducted.
It is heard in patients with cavity,

Fig 4 19 Ves1cularbreathsounds 1 Tubular phase


Fig 4 18 Auscultation 2 Alveolar phase on 1nsp1rat1on 3 On expiration

131
PRACTICAL MEDICINE

It is heard in bronchial asthma, chronic


bronchitis and emphysema. In emphysema.
breath sounds are diminished because
abnormally large amount of air dampens
the breath sounds.

II. Foreign Sounds


F,g4.20· Bronchial breath sounds l .Tubular phase. Rales: Rates are the crackling sounds that
(Alveolar phase absent) 3. On Expiration originate in the smaller bronchi or alveoli, due
to explosive opening of the airways in that part
of the lung that is deflated to residual volume.
Rates were previously believed to be due to
bubbling of air through liquid in the airways.
However this seems unlikely because:
a. Rales may be present only in inspiration.
Sounds caused by air bubbling through
fluid should be heard during both phases
Fig4 21 Vesicularbreathsoundsw1thprolonged
exp1rat1on of respiration.
b. Rales are constantly present in pulmonary
consolidation, partial collapse, open
fibrosis where there is no increase in
pneumothorax and above the level of
secretions.
pleural effusion.
Causes
There are 3 typesofbronchial breath sounds:
a. Left heart failure: Rales are present in the
A. Tubular: This is a high-pitched de-pendent parts of the lung, accentuated
b r o n c h i a l s o u n d hea r d i n by exertion.
consolidation, above the level of
b. Inflammatory exudates: Bronchitis,
pleural effusion and over cavity.
Bronchopneumonia and pneumonia
B. Cavernous: This is a low pitched
c. Lung abscess, cavity and bronchiectasis
bronchial sound heard over an
irregular cavity. d. Pulmonary congestion, edema (eg ARDS)
and fibrosis
C. Amphoric: This is a low pitched
bronchial sound with high-pitched e. COPD
over-tones heard over smooth walled Types
cavities and an open pneumothorax. a. Early inspiratory: Due to opening of
3. Vesicular Breath Sounds with Prolonged larger airways closed by the air-trapping
Expiration (Broncho-Vesicular): mechanism during the previous expiration.
They are scanty, low-pitched and not
Here there is active inspiration due to
posture dependent, e.g. chronic bronchitis.
passage of air into bronchi and alveoli
giving vesicular type of inspiratory sound. b. Mid-inspiratory: e.g. Bronchiectasis, cavity,
However during expiration there is lung abscess.
increased resistance in the airway due to c. Late-inspiratory: Due to delayed opening
spasm causing expiration to be active and of both the lungs in restrictive defects
hence equal to or more than inspiration. e.g. pulmonary edema and fibrosis. They
Since the alveolar phase is present, there are profuse, high pitched and altered by
is no pause between inspiration and posture, e.g. bending forward or lying
expiration. down reduces them.

132
(4 Respiratory System

d. Expiratory rales: These are characteristic Pleural Friction Rub


of severe-airway obstruction. They arise by
Normallythe parietal pleura slides smoothly over
the re opening of temporarily closed by the
the visceral pleura due to the presence of a thin
trapping mechanism during expiration.
layer of lubricating secretion between the two
Rhonchi: Rhonchi or Wheeze is a continuous layers. In pleural inflammation the roughened
musical sound generated by air buzzing past surfaces of pleura rub against each other giving
the airway. The lung acts like the reed of a wind rise to a characteristic friction rub.
instrument, sounding when the passage of air
Since the movement of the visceral over the
vibrates the opposing airway walls which are
parietal pleura is greatest at the lateral and
just touching.
posterior bases of the lung and decreases
Causes superiorly, the pleural rub is best heard at the
a. Bronchial asthma bases in the axillary line.
b. Bronchitis Characteristics
c. Chronic obstructive lung disease l. Rubbing or creaking
d. Localized obstruction (Malignancy) 2. Superficial sound close to the ear
e. Tropical eosinophilia 3. Accentuated by increased pressure of
the chest piece on the chest wall & deep
f. Cardiac failure
inspiration.
Types
4. Audible during both the phases of
a. Polyphonic: This is the most common type respiration, disappears on holding the
of wheezing where an expiratory musical breath.
sound contains several notes of different
5. Confined to a localized area
pitch. They result from oscillation of several
large bronchi simultaneously. 6. Not altered by coughing
7. Associated with local pain and tenderness.
b. Monophonic: This is a single musical sound
arising from a single airway brought to a Hamman' s Mediastinal Crunch : It is a clicking,
point of closure as in chronic bronchitis or rhythmical sound synchronus with cardiac
emphysema. cycle. Heard with or without stethoscope e.g.
Mediastinal Emphysema, esophageal rupture.
c. It is seldom loud enough to be heard by an
unaided ear. An except ion is stridor, a very Ill. Vocal Resonance
loud monophonic musical sound produced
The laryngeal vibrations can be normally audible
by laryngeal or tracheal obstruction.
through the stethoscope as vocal resonance.
Stridor: Stridor is a loud inspiratory sound High- pitched sounds, which are not easily
heard over the airways due to obstruction to the palpable, can be picked up as vocal resonance.
respiratory tract. The vocal resonance of normal intensity conveys
Laryngeal stridor is a high pitched sound heard the impression of being produced near the
over the larynx due to laryngeal obstruction with stethoscope. It is examined by asking the patient
foreign body, diphtheria, anaphylaxis, laryngitis, to repeat the words "one, one, one" etc. and
etc. It is a medical emergency and the patient identical points on the chest wall should be
may require respiratory support. alternately auscultated rapidly.
Tracheal stridor is a low pitched sound heard Vocal resonance may be diminished or absent
over the trachea due to tracheal obstruction. in pleural effusion, pneumothorax, thickened
N.B.: Obstruction of bronchi would cause pleura and emphysema.
wheeze or rhonchi. Vocal resonance may be increased and altered
as follows:

133
PRACTICAL MEDICINE

Table 4.4 : Respiration Findings in Various Pathological Processes


Pathological Chest Wall Movement Mediastinum Percussion Breath Foreign Vocal
Process Sounds Resonance
Sounds

Consolidation N D C Dull Tubular Rales WP+

Total collapse Retraction D s Dull Abs. Abs. Abs.

Partial Nor Retraction D s Dull Tubular Rales WP+


collapse Rhonchi
Fibrosis Retraction D s Impaired Diminished Rales Diminished

Cavity Nor Retraction D C orS Impaired Boxy Amphoric, Rales WP+


Cavernous
Pleural N D 0 Stony dull Abs below Abs Abs.below
effusion (Bronchial (Egophony
at level) at the level)
Empyema Buldging D 0 Stony dull Abs.below Abs. Abs.below
edematous (Bronchial (Egophony
at level.) at the level)
Pneumothorax N D 0 Hyper- Abs.or Am- CointTest Abs.
resonant photeric
Hydropneumothorax N D 0 Shifting dull- Abs. Succussion Abs.
ness splash
Bronchial asthma N Accessory C N Vesicular Expiratory N
Muscles with rhonchi
acting prolonged
expiration
Bronchiectasis N DorN (Usu- C N Vesicular Coarse N
ally at bases) Leathery
rales
Emphysema/COPD Barrel shaped D(Usually C Hyper- Diminished Rhonchi Diminished
bilateral) resonant vesicular
with
prolonged
expiration
N = normal. S -Same Side, 0 = Opposite Side, C = Central, D - decreased, WP= whispering pectoriloquy, Abs"" Absent,
COPD = Chronic Obstructive Pulmonary Disease

1. Bronchophony Causes: Above the level ofpleural effusion


This is increased vocal resonance where the and pneumothorax.
sounds are loud and clear but the words Mechanism: The relaxed lung above the
are not distinguishable. This is seen in pleural effusion transmits the overtones
consolidation, large superficial cavity and but dampens the lower fundamental tones
just above level of pleural effusion. giving rise to egophony.
2. Egophony 3. Whispering Pectoriloquy
When spoken voices are auscultated over Whispered voice is transmitted to the chest
the chest, a nasal quality is imparted to the wall with sufficient clarity to maintain its
sound which resembles the bleating of a syllabic character, so that individual words
goat. are clearly distinguishable as if uttered
directly into the examiner's ears.

134
( 4 ) Respiratory System
Causes Causes
a. Cavitycommunicatingwithbronchus. I. Transudative Pleural Effusion
b. Diffuse consolidation oflung adjacent
1. Congestive Heart Failure
to bronchus.
2. Cirrhosis
4. Succussion Splash
This is the splashing sound heard over the 3. Nephrotic Syndrome
chest either with the stethoscope or with 4. Pulmonary Embolization
the unaided ear applied to the chest wall, 5. Myxoedema
when the patient is shaken suddenly by the 6. Superior Vena Cava Obstruction
examiner.
II. Exudative Pleural Effusion
Causes
l. Infectious Diseases
a. Hydropneumothorax
a. Bacterial Infections
b. Large cavity containing fluid and air.
c. Herniation of stomach or colon into b. Tuberculosis
the thorax. c. Fungal Infections
5. Post-tussive Suction d. Viral Infections
A sucking sound heard over the chest wall e. Parasitic Infections
during the long inspiration that follows a 2. Neoplastic Diseases
bout of coughing. It indicate thin-walled
a. Metastatic disease
compressible lung cavity, communicating
with the bronchus. b. Mesothelioma
6. Post-tussive Rates 3. Pulmonary Embolization / Infarction
Rates which are not audible during normal 4. Collagen Vascular Diseases
respiration but are heard after making the a. Rheumatoid Arthritis
patient cough are post-tussive rales. They b. Systemic Lupus Erythematosus
signify cavity filled with thick material
c. Drug-Induced Lupus
which is dislodged during coughing
allowing air to bubble through the e. Sjogrens syndrome
remaining fluid, producing the rates. f. Wegners Granulomatosis
g. Churg - Strauss Syndrome
h. Sarcoidosis
3 Pleural Effusion 5. Gastointestinal disease
Definition: Pleural effusion is collection of excess a. Esophageal perforation
quantity of fluid in the pleural space.
b. Pancreatitis
Pathophysiology: Pleural fluid is secreted by the
c. Intraabdominal abcess
parietal and visceral layers of pleura. Majority of the
fluid is absorbed by the lymphatics and the remainder d. Amoebic Liver Abcess
is absorbed by the lung or chest wall across the meso­ e. Diaphgramatic hernia
thelium. Excessive fluid collects (according to Frank f. After abdominal surgery
Starlings law of hydrostatic pressure) due to excessive g. Post-liver transplant
back pressure from the visceral surface (e.g. CCF),
6. Drugs and Toxins
decrease in serum proteins (e.g. nephrotic syndrome),
pulmonary inflammation or lymphatic obstruction a. Drug induced pleural diseases
( e.g. pneumonia, infiltrating tumor) or increase nega­ Nitrofurontoin, Methylsergide,
tive pressure in pleural space (e.g. Atelectasis). Bromocriptine
b. Toxins : Asbestos
135
PRACTICAL MEDICINE

7. Traumatic: 5. Subphrenic abscess rupturing into thoracic


a. Chest wall trauma cavity
b. Iatrogenic injury 6. Tuberculosis
c. Post coronary artery bypass-surgery III. Hemorrhagic Effusion (Hemothorax): Blood
in pleural cavity i.e. Hematocrit of pleural fluid
d. Hemothorax
should be more than half of that of Peripheral
e. Radiation Injury blood. HCT of 1-20% is usually seen in
8. Chronic Uremia carcinoma, trauma, pulmonary embolism.
9. Cardiac Disease Causes:
a. Post myocardial infarction syndrome 1. Trauma whilst tapping or central line
(Dressler's syndrome) placement
b. Pericardia! diseases 2. Iatrogenic
IO. Others: 3. Tumour
a. Septicemia, 4. Tuberculosis
b. Drug Allergies, 5. Pulmonary infarction
c. Bleeding disorders, 6. Acute hemorrhagic pancreatitis
d. Chylothorax, 7. Bleeding or hemorrhagic disorders
e. Meig's syndrome (ovarian fibroma 8. Coxsackie B virus infection
with ascites and right pleuraleffusion) IV. Tuberculous Pleural Effusion (Refer Pg. 141)
Types This is usually an exudate, rarely bilateral and
hemorrhagic and may be AFB positive and
I. Acute Pleural Effusion culture positive.
Causes:
V. Mill-y Effusion (Chylous, Opalescent)
l. Trauma A. Chylothorax: Pure chyle contains more
2. Acute pancreatitis than 400 mg of fat per 100 ml. Many large
3. Pulmonary infarction fat globules are present. Triglycerides> 110
4. Ruptured amebic liver abscess into the mg/di.
pleural cavity Causes:
5. Rupture of esophagus l. Trauma to thoracic duct
6. Dissecting aneurysm of aorta leaking into 2. Filariasis
the pleural space 3. Tuberculosis
II. Purulent Effusion (Empyema): Pus in pleural 4. Malignant growth of mediastinal
cavity glands
Causes: 5. Thrombosis ofleft subclavian vein
l. Pyogenic infections:pneumonia, lung B. Chyliform: Fat present is not derived from
abscess, bronchiectasis the thoracic duct but from degenerated
2. Septicemia cells. The fat globules are smaller.
3. Penetrating wounds of chest, chest tube Causes:
trauma, surgical procedures I. Tuberculosis
4. Rupture of esophagus 2. Carcinoma of lung and pleura
C. Pseudochylous: Milky appearance of the

136
{ 4 > Respiratory System

M
fluid is not due to fat but due to lecithin, MIid Pleural Effusion
Rluo1;nUCJ11
on Plmn,-ray<lic>I
r

globulin and calcium phosphate. ('P,nglo


1ppc.1rs
when
Causes: IS010

�:�;£;�, '::::1
200cc
I. Tuberculosis of
flu,J
collecls P,'i\4fili'
2. Nephrosis
3. Heart disease
4. Malignancy
llypoccbolc
•lomogt.'flOW
D. Cholesterol Effusion: Peculiar glistening, Mo<lcra1c Lo Scwrc

opalescent appearance of fluid due to


::c;:tr '\
t..1<ro-
Effu�ion nuMI
collcc1ion
mcJ�I.

__'\,
cholesterol crystals. ,.,_,.
mfcnor
i,;,p11r.,�il.

Causes: ----Ab..0« of
A11 bronchogram
- -� ..
Long-standing effusion, e.g. tuberculosis, :mJ broncbo�' asculor
markings(cfr,ncumonl31
carcinoma, nephroticsyndrome, myxedema
and post myocardial infarction.
VI. Iatrogenic Pleural Effusion (including Drug­
•llc•rt
induced)
Lung
U)·podcnS<" lluid �n in
Causes: 1hc dcpend.an1 J')()Akl'II ...

1. Dialysis, especially peritoneal CT Scan

2. Following thoracic surgery


3. Post-central line placement

id
4. Drugs e.g. Practolol, methysergide
5. Drug induced eosinophilia e.g. aspirin,
PAS, sulphonamides, nitrofurantoin
6. Drug-induced lupus e.g. hydralazine, F,,..,.� Loculatod EfTu,ion
procainamide, alpha methyl dopa l:ITUSl<)fl•
'Van1shtng.
Appc:irs ,\p�'31'$
Tumour'
C011nJ. Cigar-shaped
VII. Recurrent Pleural Effusion liC'C'1I in
CCF
Causes: �fajor
fissure
I. Tumors ::. APV)C,.,· Later.al View

2. Tuberculosis Angl� with


,h,,.1w••
1 .. � ChcSl-��u
obc�c- . loculation
3. Collagenosis
Mal'Hinis /
4. Cardiac failure convex
mcd1all}'
VIII. Bilateral Pleural Effusion
Causes:
Fig 4 22 ·Pleural Effusion
l. All conditions causingTransudativepleural
effusion IX. Phantom (Vanishing) Tumor
2. Pleural metastasis This is a loculated fissural effusion in the lungs
3. Lymphoma due to cardiac failure. It vanishes with anti failure
therapy like diuretics and does not need pleural
4. Pulmonary infarction
tapping.
5. Tuberculosis
6. Asbestosis Diagnosis
7. Septicemia I. Symptoms
8. Rheumatoid disease, SLE, etc. A. Pleuriticpain: Pain in chest which increases

137
PRACTICAL MEDICINE

F,g.4 23 X 'ayo'p'eura1ef:us•on Mesothe on'a,show ng ,


increased density of hem thorax with central med1astinum
and consol,dat1on due to pne,..-nor"a
--- ----- - -- --
on inspiration, coughing, laughing and 2. Shift of the mediastinum to the
sneezing. opposite side.
B. Dyspnea: lf massive collection of fluid 3. Diminished or absent TVF on the
occurs rapidly. affected side below the level of the
fluid and increased TVF at the level
C. Dry cough of the fluid.
D. Systemic symptoms : (may or may not be C. Percussion:
present) fever, anorexia, malaise, weight
loss, indicative of underlying disease. I. Stony dullness with increased
resistance and no shifting dullness
II. Signs: {500 cc of fluid is required to produce below the level of fluid.
signs).
2. Skodaic resonance (boxy note) just
A. Inspection: above the effusion.
l. Bulging of intercostal spaces on the 3. Obliteration of Traube's space if left
affected side with fullness of hypo­ sided effusion.
chondrium if large effusion.
4. Grocco's triangle: Triangular area of
2. Diminished mobility ofthe chest wall dullness against the vertebral column
on the affected side. at the base of the opposite lung, due
3. Shift of the mediastinum to the to collapse of that lung.
opposite side. i.e. Trailes sign positive 5. Ellis' S shaped curve:
(sternomastoid muscle on the side of
the mediastinal displacement may be a. It is a radiological illusion.
prominent) as shift of trachea to one b. In free pleural effusion the fluid
side causes relaxation of deep cervical collected in the pleural space
fascia on that side and apex impulse assumes the highest position in
is displaced to the side opposite to the axilla due to capillary action.
effusion. Hence the stony dullness arising
B. Palpation posteriorly near spine reaches
the highest point in posterior
I. Diminished mobility of the chest on axilla and then again comes down
the affected side. anteriorly.

138
( 4 ) Respiratory System
D. Auscultation: B. Hemorrhagic
1. Diminished or absent breath sounds C. Milky
below the level of the effusion.
D. Greenish: Pseudomonas, Streptococcus,
2. Bronchial breathing at the level of
Pneumococcus
pleural effusion due to relaxed lung.
3. Egophony at the level of the pleural E. Gold paint: myxedema
effusion. F. Anchovy sauce - ruptured amebic liver
4. Diminished or absent vocal fremitus abscess
below the level of the fluid. II. Microscopic
III. Investigations: A. Lymphocytic predominance - chronic
A. CBC,ESR conditions like tuberculosis, resolving
B. Sputum Examination: Gram and Ziehl­ pneumonia, fungal infections, carcinoma
Neelsen's stain and culture. and myxedema
C. X-ray chest B. Polymorphic predominance - Acute
L Homogenous opacity conditions like acute bacterial infections
2. 0 bliteration of costophrenic angle on and rheumatic fever
the affected side ( 150 ml of fluid) C. Eosinophilic predominance
3. Concave upper border (Eilis's curve)
4. Shift of the mediastinum to the Table 4.5 : Pleural Fluid with and without
Systemic Eosinophilia
opposite side
With Systemic Without Systemic
Radiologically, pleural effusion can be
Eosinophilia Eosinophi/ia
classified as free or loculated as given
1. Tropical eosinophilia. 1. P/europulmonary am-
below:
ebiasis
1. Free classical: Mild (blunting
2. Pulmonary eosinophi lia 2. Fungal infection
of costophrenic angle on lateral
decubitus view) or moderate to 3. Vasculitis e.g. Polyarteritis 3. Foreign protein in pleural
severe (homogenous opacity with nodosa space
classical lateral-medial, superior­ 4. Hydatid disease 4. Blood in pleural space
inferior curve with mediastinal shift 5. Hodgkin's disease 5. Collagen disease. SLE
to opposite side.
6. Drug induced 6. Pulmonary infarction
2. Free subpulmonic: additional elevation
of diaphragm 7. Frequent aspiration

3. Loculatedfissural: Phantom/vanishing 8. Post-CABG


tumor (Refer Pg. 137)
4. Loculated along the chest wall D. WBC Count> 10,000 I mm3 - Empyema,
D. Imaging: Ultrasound, CT scan, HRCT scan Pancreatitis, Pulmonary Embolis m,
(50 ml of fluid)
Carcinoma, Collagen Vascular Diseases.
E. lhoracocentesis to differentiate transudate III. Biochemical Investigations:
from exudate A. Proteins more than 3 gm% - exudate; less
F. Pleural Biopsy than 3 gm% - transudate.
G. lhoracoscopy B. Sugar diminished in rheumatoid arthritis,
Specific Features of Different Pleural infections, malignancy.
Effusions (Pleural Fluid Analysis) C. LDH increased in tuberculous effusion.
I. Gross D. Amylase increased in pancreatitis rupture
A. Purulent / serous of esophagus and salivary gland abscess.

139
PRACTICAL MEDICINE

E.Adenosine deaminase activity is increased II. Table 4.7: Differences Between


in tuberculous pleural effusion. Empyema and Pleural Effusion
F. Hyaluronidaseis increased in mesothelioma Empyema Pleural
of pleura. Effusion

G. Light's criteria using serum and pleural fluid 1. Septicemia /Toxic look Present Absent
albumin and LDH are used to differentiate 2. lntercostal spaces Red, shiny, edema- Normal/
transudate from exudate. tous, tender Bulging
Exudative Pleural Effusion meets atleast 3. Clubbing Present Absent
one criteria, Transudative meets none:
4. Opacity on X-ray Obliterates the rib Not so
i. Pleural fluid protein / serum protein shadows
> 0.5.
Ill, Table 4.8: Differences Between
ii. Pleural fluid LDH / serum LDH > 0.6.
Pericardia! and Pleural Effusion
iii. Pleural fluid LDH more than two
Pericardia/ Pleural effusion
thirds normal upper limit for serum. effusion
These cr iteria misid entify 25% of
1. Mediastinal Absent Present
transudates as exudates. shift
H. Serum-to-pleural fluid albumin gradient
2. Dullness poste- Absent Present
(ser um albumin minus pleural fluid riorly
albumin) of < 1.2 g/dL indicates the
3. Traube's area Not obliter- Obliterated in left
presence of exudate. Difference >3.1 gm/ ated sided effusion
di indicate it is Transudative.
4. Heart sounds Muffled Diminished atthe
Sequelae of Pleural Effusion apex, but heard better
elsewhere
l. Permanent collapse of the lung (compression
collapse) IV. Table 4.9 : Differences between Liver
2. Pleural thickening. adhesions and bronchiectasis Abscess and Right Pleural Effusion
3. Empyema Liver Abscess Right Pleural
Effusion
Differential Diagnosis
1. Dullness highest In the mid- In theaxilla
I. Table 4.6: Differences between point clavicularline
Thickened Pleura and Pleural 2. T idal percussion No movements of Movements
Effusion diaphragm may be present
ThickenedPleura Pleural Effusion 3. lntercostal tender- Present Present only in
1. History Long standing Acute ness empyema
2. Intercostal Depressed Bulging V. Effusion due to Heart Failure
spaces
l. Most common cause of pleural Effusion.
3. Mediastinum No shift or shift to the Shift to the op-
same side posite side 2. It is Transudative and usually bilateral.
4. Percussion Dull Stony dull with 3. Diagnostic thoracentesis is usually not
note increased resis­ required. Heart failure should be treated.
tance
4. A pleural fluid NT - ProBNP > 1500 pg/ml
S. Breath sounds Diminished Absent is diagnostic of pleural effusion secondary
6. X-ray No dense opacity, Dense opacity, to congestive heart failure.
upper level not well- concave upper
defined, cosophrenic border, cos to· VI. Synpneumonic or Parapneumonic Effusion :
angle not obliterated, phrenic angle This is said to occur when there is simultaneous
calcification may be obliterated pneumonia in the lung covered by pleural
seen
effusion.

140
( 4 > Respiratory System
l. It is associated with bacterial pneumonia, pleural effusion, collapse, consolidation,
Lung abscess, or bronchiectasis which are congestion or a local area of dullness.
the most common causes of exudative 4. Pleural fluid is exudative, glucose level is
pleural effusion. It is also associated with reduced.
malignancy and pulmonary infarction.
5. For definitive diagnosis : Pleural fluid
2. Patient usually present with Acute cytology (diagnostic), other modalities like
(Bacterial) orsubacute (Anaerobic) onset of Thorocoscopy, CT or USG guided biopsy
fever, chest pain, cough with expectoration; of pleural thickening / nodules.
weight loss and mild anaemia if subacute.
VIII. Mesothelioma
3. The physical findings of pleural effusion
1. Primary tumours of mesothelial cells lining
which are altered are:
the pleural cavities; most related to Asbestos
a. Bronchial breath sounds are very well exposure.
heard
2. Patients have chest pain and shortness of
b. Rales may be present breath.
c. Vocal resonance is increased because 3. Most signs are similar to pleural effusion
the relaxed lung is filled with exudate due to other causes, but mediastinal shift
in consolidation, which is a good will be to the same side.
conductor of sound.
4. X-ray chest-Generalised pleural thickening
4. Following features may indicate empyema: with shrunken hemithorax.
a. Patient not responding to current 5. Thoracoscopy or open pleural biopsy
antibiotics. establishes the diagnosis.
b. Grossly purulent fluid. 6. Treatment
c. Pleural fluid WBC > 50,000 / µI or a. Opiates for chest pain
PMN > 1000 / µl.
b. Oxygen for shortness of breath.
d. Pleural fluid pH < 7.20. (other causes
- oesophageal rupture, Rheumatoid IX. Effusion secondary to pulmonary embolization
pleural, TB pleuritis, Lupus Pleuritis) 1. Patient usually presents with Dyspnea.
e. Pleural fluid glucose < 60 mg/di. 2. Pleural Effusion is exudativeortransudative.
f. LDH > 1000 IU/L. 3. Treat underlying emboli i.e. Anticoagula­
g. Positive Microscopy or culture of tion. If pleural effusion increases in size
pleural fluid. after anticoagulation, patient has either
h. TNFa levels higher than 80 pg/ml recurrent emboli or a complication like
also suggest Empyema. Hemothorax or Pleural infection.
VII. Effusion Secondary to Malignancy X. Tuberculous Pleural Effusion
l. Second most common type of Exudative l. Usually associated with primary TB and
Pleural Effusion. Lung carcinoma, Breast occurs due to hypersenstivity reaction to
carcinomaand Lymphoma accountfor75% tuberculous protein in pleural space.
of cases. 2. Clinical features : Fever, weight loss,
2. Dyspnea is out of propectin to the size of dyspnea, pleuritic chest pain, dry cough
pleural effusion. Other systemic features to along with classical signs of pleural effusion.
note are - weight loss, cachexia, clubbing, 3. Pleural fluid examination:
non-metastatic manifestations of the a. Exudate with small lymphocytes
tumor. predominant
3. Patient may present with signs of

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PRACTICAL MEDICINE

b. ADA> 40 IU/L, IFN y> 140 pg/ml b. Refractory hydrothoraxmanagement


c. Pleural fluid culture i. T horacent esis - diur etic s
4. Needle biopsy ofpleura or thoracoscopy if should be continued even after
required. thoracentesis. Not more than 2
5. Treat underlying TB litres of pleural fluid should be
XI. Effusion Secondary to Viral Infection removed, to prevent pulmonary
I. 20% of undiagnosed exudative effusions. edema and hypotension.
2. These effusions resolve spontaneously with ii. Transjug ula r intrahepatic
no long term residual effusion. portosystemic shunt (TIPS).
3. Aggressive Management is not required, iii. Pleurodesis - Mechanical I
particularly if patient is improving. chemical.
XII. Hepatic Hydrothorax iv. T h o r a c o s c o p i c r e p a i r •
l. Defined as Pleural Effusion, usually greater Diaphgramatic repair involving
than 500 ml, in patients with cirrhosis and a pleural flap and surgical mesh
without primary cardiac, pulmonary or reinforcement.
pleural disease. Pleural effusion occurs in 6. Treatment of infection - spontaneous
5-10% of patients with cirrhosis. bacterial empyema.
2. Pathogenesis 7. Other treatment options - Octreotide,
Results from passage of peritoneal fluid terlipressin with albumin.
through small openings in the diaphgram XIII. Chylothorax
into the pleural space. The negative intra
I. Causes : Trauma (Most frequently during
thoracic pressure favours the passage of
fluid from intra-abdominal to the pleural thoracic surgery), Tumor in mediastinum.
space. 2. Patients have dyspnea and present with
3. Clinical manifestations large pleural effusion.
a. Patients present with shortness of 3. Pleural fluid : Milky fluid, Triglyceride
breath, cough, hypoxemia, chest levels> 110 mg/di.
dicomfort. 4. Lymphangiogram and Mediastinal CT scan
b. Ascites is not always present, although for Tumor / lymph nodes should be done
other features of cirrhosis may be if trauma is not the cause.
present. 5. Treatment
c. Less common presentation a. Insertion of I CD, octreotide.
i. Tension hydrothorax - severe
b. Pleuoperitoneal shunt if above
dyspnea, hypotension.
modalities fail.
ii. Spontaneous Bacterial Empyema
c. Ligation of thoracic duct
- defined as PMN cell count> 500
cells/ mm > or positive culture with 6. Avoid prolonged ICD drainage of
exclusion of a parapneumonic chycothoracesas it will lead to malnutrition
effusion. and immunologic incompetence.
4. Pleural effusion is transudat ive but XIV. Hemothorax
thoracentesis is always done to rule out 1. Diagnosed when hematocrit of pleural fluid
other causes of pleural effusion. is more than one-half of that in peripheral
5. Management blood.
a. Sodium Restriction, diruetics ( similar 2. Causes • Trauma, rupture of blood vessel
to ascites) or tumor

142
(4 > Respiratory System
3. Treated with Tube Thoracostomy. It also 3. Chest physiotherapy to encourage expansion
allows quantification of bleeding. oflower chest
4. Lacerated pleura treated by apposition of 4. For recurrent pleural effusion e.g.
pleural surfaces. malignancy.
5. If pleural hemorrhage exceeds 200 ml/h, 1. Pleurodesis - Pleural abrasion, Talc,
thoracoscopy or thoracotomy should be Doxycydine.
done. 2. Placement of Sma ll Indwelling
XV. Miscellaneous causes Catheter
1. Serum Amylases level elevated in II. ForEmpyema
oesophageal rupture or pancreatitis I. Antibiotics: The correct antibiotic could be
2. Intra abdominal abcess - Patient is febrile, best selected by culturing the pleural fluid
high PMN in pleural fluid; no pulmonary followed by antibiotic sensitivity tests. The
pathology. antibiotics have to be given for 3-6 weeks or
even more till the patient becomes afebrile,
3. Ascites with pleural effusion - Benign
WBC count returns to normal, drainage
ovarian tumor (Meig's syndrome), Ovarian
reduces to less than 100 ml/day and there
hyperstimulation syndrome.
is radiological clearance. The antibiotics
4. Post CABG: (a) Effusion within first few used are a combination of Beta-lactam
weeks are typically left sided, bloody, large aminoglycoside and metronidazole.
numbers of eosinophils, responding to one 2. Intercostal drainage: Continuous intercostal
or two thoracentesis; ( b) Effusions after first drainage with a tube may be required till the
few weeks are typically left sided, dear, with patient is afebrile, lung expansion is full and
small lymphocyte predominance and tend WBC count returns to normal.
to recur.
3. Intrapleural thrombolytic agents like streptokinase
Treatment diluted in l O ml saline breaks down the loculation
and improves drainage.
I For Pleural Effusion
4. Thoracostomy with decortication.
1. General: Rest, adequate nutrition, vitam ins
5. Video Assisted Thoracic Surgery.
2. Management offluid: Thoracocentesis or
6. Open drainage and rib resection.
pleural tapping if large effusion, cardio-
respiratory embarrassment or empyema
4 > Collapse / Atelectasis of
Lung������­
Definition
It is defined as airlessness with shrinkage of the lung
which may be secondary to obstruction, compression,
contraction or surfactant loss. Failure of the lung to
expand at birth is called atelectasis neonatorum.
Classification
l. Acute or chronic - depending on rapidity of
development of collapse.
2. Partial or total - depending on the degree of
collapse.

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PRACTICAL MEDICINE

side, dry cough, breathlessness and fever.


Presence of symptoms depends on:
A. Amount ofthe lung involved.
B. Rapidity with which it occurs.
C. Presence or absence of infection
II. Signs: Refer Table 4.4, Pg. 134
III. Investigations
1. X-Ray chest
a. Opacity of the involved segment or lobe
producing silhouette sign
i. Middle lobe or lingular collapse
producing blurring of Right or left
heart border.
ii. Upper lobe collapse causing blurring
of superior mediastinal border.
Luftsichel sign - In case ofcomplete
upper ·1obe collapse hyperinflation
Fig 4 26· X-ray showing collapse right upper lobew1th
consolidation and CT Chest showing collapsed lung
of apical segment of lower lobe
------------ - ----- -- --------- -- restores the silhouette ofmediastinal
3. Mechanism of collapse · obstruction, boundaries.
compression, fibrosis or surfactant loss.
iii. Lower lobe atelectasis does not
Causes obliterate cardiac borders (negative
silhouette sign) and causes a
I. Compression collapse retrocardiac shadow. Superior
A. Pneumothorax triangle sign - Lower lobe collapse
B. Large neoplasm resulting in para - tracheal opacity
C. Pleural effusion due to displacement of superior
mediastinal structure.
IL Absorption collapse (due to obstruction)
iv. Double Lesion Sign : Results from
A. Within the lumen: collapse of two segments or lobes,
1. Foreign body which cannot be explained by one site
2. Mucus plugs ofobstruction. It is useful to exclude
3. Blood a malignancy.
B. Within the wall b. Signs ofloss oflung volume
Neoplasm e.g. adenoma, carcinoma i. Shift ofhilum.
C. Outside the wall ii. Shift ofTrachea or Mediastinum.
1. Aneurysm ofaorta iii. Elevation ofhemi-diaphgram
2. Enlarged lymph nodes iv. Crowding of bronchi/ blood vessels.
3. Neoplasms c. Hyperinflation of rest oflung.
2. Computed Tomography Scan (CT Scan)
Diagnosis
a. Findings similar to X-ray chest
I. Symptoms b. In addition, helps to determine site of
The common symptoms are: Pain on the affected obstruction and etiology.

144
{ 4 > Respiratory System
c. Useful in evaluating mediastinum, ILD usually have an acute I chronic phase.
pleura, hilum, chest wall, rest of lung and They can occassionally be recurrent with intervals of
concomitant pathologies. sub•dinical disease.
3. Other Imaging Techniques : MRI, Virtual Histopathologic patterns in ILD :
Bronchoscopy.
l. Desquamative Interstitial Pneumonia (DIP)
4. Pulmonary Function Test : Shows a restrictive
pattern of abnormality. 2. Respiratory Bronchiolitis

Arterial Blood Gas Analysis: Shows Hyp oxemia 3. Diffuse Alveolar Damage (Acute or Organizing)
5.
particularly if acute. 4. Bronchiolitis Obliterans with Organizing
Pneumonia (BOOP)
Complications
5. Non-specific Interstitial Pneumonia (NIP).
]. Infection 6. Usuaul Interstial Pneumonia (UIP).
l. Spontaneous pneumothorax from ruptured 7. Lymphocytic Interstitial Pneumonia.
bullae of compensatory emphysema
Diagnosis
Treatment
l. Duration of Illness:
Aims at treating underlying cause.
i. Acute Presentation (days to weeks) :
1. Pleural Aspiration / ICD in pleural effusion / (a) Allergy (drugs, fungi, helminths),
pneumothorax, hydropneumothorax. (b) Acute Interstitial Pneumonia
2. Removal of foreign body, impacted mucus. (AIP), (c) Eosinophilic Pneumonia, (d)
Hypersensitivity Pneumonitis {unusual)
3. Treatment of endobronchial tumor - surgery,
radiation, chemotherapy, laser, airway stenting. ii. Subacute Presentation (weeks to months)
may occur in all ILD : (a) Sarcoidosis,
4. In case of mucus plugg ing. Mucolytis,
(b) Drug Induced ILD, (c) Alveolar
nebulization, physiotherapy, measures like
Hemorrhagic Syndrome, (d) Cryptogenic
postural drainage, chest wall percussion and
Organizing Pneumonia (COP), (e) Acute
vibration, forced expiration technique.
Immunologic Pneumonia - complicating
5. Oxygen, Analgesics, Antibiotics for secondary SLE or Polymyositis.
infection.
iii. C hronic Pre sentation (months to
years) (Most ILD) : (a) Sarcoidosis, (b)

5 > Pulmonar Fibrosis/


Idiopathic Pulmonary Fibrosis, (c) Primary
Langerhans Cell Histiocytosis {PLCH),
Interstitial Lung Eosinophilic Granuloma or histiocytosis,
Diseases (d) Pneumoconioses, (e) Connective Tissue
Disorders.
Definition iv. Episodic Presentastion (Rare) : (a)
Hypersensitivity pneumonitis, (b) COP, (c)
Represent a large number of conditions that involve Eosinophilic pneumonia, (d) Pulmonary
the parenchyma of the lungs - the alveoli, the alveolar Vasculitides, (e) Pulmonary hemorrhage,
epithelium, the capillary endothelium, spaces between (f) Churg Strauss Syndrome.
these structures, as well as perivascular and lymphatic
tissues. 2. Age
a. Presentation - Between 20 and 40 Years
They have similar clinical, roentgenographic, physi­
- Sarcoidosis, CTD associated ILD,
ologic or pathologic manifestations.
Lymphangio-leiomyomatosis (LAM),

145
PRACTICAL MEDICINE
--�---------------------------�
Classification of lnterstial Lung Diseases (ILD)

!
Predominant Inflammation
Based on Histopathology
l
Predominant Granulomatous
and Fibrosis reaction

I
IAlveolitis, Interstitial Inflammation IGranulomasl

I
and fibrosis)

!
Etiology
l
Etiology
! l
Etiology Etiology
Known Unknown Known Unknown
1. Asbestosis 1. Idiopathic Interstitial Pneu­ 1. Hypersensitivity 1. Sarcoidosis
2. Fumes, Gases monia, IPF, DIP. All'. COP. Pneumonitis 2. Granulomalous
3. Radiation NIP. (organic dusts] vasculitides
4. Aspiration pnl'u· 2. Connective Tissue Diseases - 2. Inorganic Dusts : :1. Wegners Granulo­
monia SLE, RA AS, SS, Sjogrcn's Silica. Beryllium matosis, Polyangi­
5. Residual of ARDS Syndrome tis, Churg Strauss.
6. Drug (Antibiotics, 3. Pulm. Hemorrhage syn­ 4. Langerhans cell
Amiodarone, Gold dromes e.g. good pastures. granulomatosis.
& Chemotherapy 4. Pulm. Alveolar Proteinosis 5. Bronchocentric
drugs. 5. Lymphocytic infiltration granulomatosis
7. Smoking, Related disorders 6. Lymphomatoid
DIP, Respiratory 6. Eosinophilic pneumonia gra nu I omatosis
Broncholitis, 7. Lymphangioleiomyomatosis
Primary Langer- 8. Amylodosis
hans Cell Histiocy- 9. GVHD (Graft versus Host
tosis (PLCH) Disease)
10.GI / Liver Disease Inflamma
lory Bowel Disease. Primary
Biliary Cirhosis
11.Inheriled disease : Tuberous
sclerosis, Neurofibromatosis.
ARDS: Adult Respiratory Distress Syndrome; ILD: Interstitial Lung Disease; DIP: Desquamative Interstitial Pneumonia:
IPF : Idiopathic Pulmonary Fibrosis; AIP : Acte Interstitial Pneumonia: COP : Cryptogenic Organising Pneumonia;
NIP : Non-Specific Interstitial Pneumonia; SLE : Systemic Lupus Erythematosus; RA : Rheumatoid Arthritis;
AS: Anklyosing Spondylitis; SS : Systemic Sclerosis; GI : Gastro Intestinal

PLCH, Inherited forms (familial !PF, c. Familial Clustering - Sarcoidosis


Gauches, disease. d. Familial Lung Fibrosis (older age, male
b. Presentation older than 50 years - !PF. sex, history of smoking are risk factors)
3. Gender Mutations in surfactant (characterized by
a. LAM and Pulmonary involvement several patterns - NIP, DIP, UIP)
in Tuberous Sclerosis - Exclusively in 5. Smoking History:
Premenopausal women. a. 60% to 75% with !PF • have History of
b. ILD in CTD - more common in men smoking.
(exception ILD in RA} b. Almost or always current smokers -
c. Pneumoconiosis -More frequently in men. PLCH, DIP, Good Pastures syndromes,
4. Family history Respiratory Broncholitis, Pulmonary
a. Autosomal Dominant Pattern - ILD in Alveolar Proteinosis.
Tuberous Sclerosis & Neurofibromatosis. 6. Occupation and Environmental History :
b. Autosomal Recessive Pattern • Niemann Symptoms diminish or disappear after patient
Pick, Gauchers, Her mansky Pudlak leaves the site of exposure; symptoms reappear
Syndrome. on returning to exposure site.

146
( 4 > Respiratory System

I Repetitive Exogenous and Endogenous Stimuli!

j
Dust, Fumes,
Drugs, Infection,
Cigarette Smoke,
Radiation, other diseases
Autoimmune disorders

Microscopic Lung Injury


Separated Spatially and Temporally

j -
Wound
Intact ------ --
-, Healing >------ Abberant

Genetic predisposition
- Autoimmune condition
- Superimposed diseases
I Lung Homeostasis I - Excess inury to lung may overwhelm
reparative mechanisms

Predominant Predominant
Granulomatous R�ponse

Organisation ofT Lymphocytes Injurty to Epithelial


Macrophages, Epitheloid cells Surface
into Granulomas in Lung !
Parenchyma Inflammation in Air
Spaces & Alveolar walls
Interstitial !
Fibrosis Inflammation spreads to
adjacent portions of
Interstitium & vasculature

!Interstitial Fibrosis !
All these lead to irreversible scarring of alveolar Airway & Vasculature

, Fig. 4 28. Pathoges1soflLD

e.g. Hypersensitivity pneumonitis - symptoms pneumonia grouped under interstitial lung disease
temporally related to hobby (pigeon breeders) with predominant inflammatory type and unknown
or workplace (Farmer's lung). etiology. It has poor response to treatment and Bad
7. Other important past history Prognosis
a. History of Travel - for parasitic infection Clinical Manifestations
(causing pulmonary eosinophilia).
1. It has a chronic presentation : Age Group > 50
b. History of risk factors for HIV infection
yrs, Men more commonly affected; 60% to 75%
from all patients : Several processes occur
are smokers.
at time of initial presentation or during
clinical course. e.g. HIV Infection, BOOP, 2. Symptoms
AIP, Lymphocytic Interstitial Pneumonitis a. Exertional Dyspnea
or Diffuse Alveolar Hemorrhage. b. Non productive cough
Idiopathic pulmonary fibrosis: (diffuse c. Fatigue
fibrosing alveolitis) (Hamman Rich d. Weight loss
syndrome) 3. Signs
It is the most common type of idiopathic interstitial a. Tachypnea

147
PRACTICAL MEDICINE

b. Cyanosis : especially in advanced stages iii. CO 2 retention - late stages


c. Clubbing: especially in advanced stages iv. Exercises or sleep induced hyponemia.
d. Bi-Basilar End Inspiratory Leathery 10. Cardio - pulmonary exercise testing
Crackles. i. Exercise testing with ABG monitoring to
4. Manifestation of Pulmonary Hypertension and look for Arterial 02 desaturation
Cor Pulmonale in Mid -Late stages of disease. ii. Serial Assessment ofresting and exercise gas
exchange - excellent method for following
Investigation
disease activity and response to treatment.
I. Routine Tests - CBC, Sr. Creatinine, FBS iii. 6-Minute walk test
2. LDH - Non specific finding Global evaluation of sub -maximal exercise
3. Other tests - To rule out other diseases. e.g. ANA, capacity.
RF - nonspecifically present in all ILF. Walk distance and level of O2 desaturation
4. ECG -If PHT present -RVH, RAH, P-pulmonale. correlate with patient baseline lung
function and mirrors patients clinical
5. 2-D Echo • If PHT present - Rt. ventricular
course.
dilatation and/or hypertrophy.
11. Histopatho/ogy
6. CXR - Bi basilar reticular pattern; It correlates
poorly with clinical or histopathologic stage of Essential to confirm UIP pattern for diagnosis.
disease. Honey combing, if present, correlates Surgical Bx required (Transbronchial Bn� Biopsy
with pathologic findings of small cystic spaces not helpful).
and progressive fibrosis and when present has Histologic features
poor prognosis. CXR may be normal. i. Affects peripheral, sub pleural parenchyma
7. HRCT - Patchy, predominantly basilar, more severely.
subpleural reticular opacities, associated with ii. Histologic hallmark / chief diagnostic
traction bronchiectasis and honeycombing may criteria.
also preclude the need for biopsy to diagnose Heterogenous appearance at low
IPF. magnification with alternating areas of
8. Pulmonary Function Tests normal lung, interstitial inflammation, foci
A. Spirometery and Lung Volumes - of proliferating fibroblasts, dense collagen
i. Proven to have prognostic valve. fibrosis, honey comb changes.
iii. Patchy interstial Inflammation with
ii. Restrictive defect- J..TLC, J..FRC, J..RV,
lymphoplasmocytic infiltrate in alveolar
-1..FEV & tFVC (related to iT LC);
septa; Hyperplasia of Type 2 pneumocytes
FEV 1 / FVC normal or increased.
iv. Fibrotic zones : Composed of dense
B. Diffusion Capacity
collagen, Extent of fibroblastic proliferation
i. Diffusion capacity oflung for carbon - predictive of disease progression.
monoxide (DLCO) is reduced - Due to v. Honeycomb changes
effacement of alveolar capillary units
and V /Q mismatch. Cystic fibrotic air spaces - lined by
Bronchiolar epithelium and filled with
ii. Severity ofreduction does not evaluete mucin.
with disease stage.
vi. Smooth muscle hyperplasia - present in
9. Arterial Blood Gases (ABG) areas of fibrosis and honey combing.
i. Resting Hyp onemia - may or may not be (Usual Interstitial Pneumonia -For patients
present. in whom lesion is idiopathic and not
ii. Respiratory alkalolies. associated with another condition.)

148
( 4 > Respiratory System

Treatment Table 4.1 O : Differences between


Collapse and Fibrosis
There is no effective therapy for IPF.
Co!lapu1 fibrosis
1. Hypoxemia (Pa0 2 55 mmHg) at rest and I or
with Exercise - supplemental 02 • I.Onset Acute Chronic

2. Cor pulmonale - diuretics, other treatment. 2. Chest wall Flattened Retracted

3. Pulmonary Rehabilitation. 3. Breath sounds Absent Feeble but never absent

4. Lung Transplantation

6
1. Pathologic and Radiologic evidence ofUIP
AND Pneumothorax
2. Any of the following criteria Definition: Pneumothorax refers to air within the
a. DLC02 < 39%. · pleural space.
b. Decrement in FVC :a 10% during 6 Causes
months of follow up.
A. Primary Spontaneous Pneumothorax (PSP)
c. Decrease in Sp02 below 88% during
It is a pneumothorax that occurs without a
6 min - walk test.
precipitating event in a person who does not have
d. Honey combing on HRCT known lung disease. Usually most individuals
Patients with IPF andco-existantemphysema (COPD) with PSP have unrecognized lung disease, with
develop pulmonary hypertension early and have a the pneumothorax resulting from rupture of a
worse outcome. subpleural bleb.
Acute deterioration ofIPF & Acute Exacebration Risk Factors
1. Acute deterioration secondary to 1. Smoking: Cigarette smoking is a significant
a. Infection risk factor. Respiratory bronchiolitis, a form
of airway inflammation associated with
b. Pulmonary Embolism
cigarette smoking, may contribute to the
c. Pneumothorax development and recurrence of PSP.
d. Accelerated clinical course 2. Family history : Autosomal dominant,
Exacerabation ofIPF -Criteria for diagnosis autosomal recessive, polygenic, and
i. Worsening dyspnea within few days X-linked recessive inheritance mechanisms
to 4 weeks have all been proposed. The autosomal
dominant Birt-Hogg-Dube syndrome,
11. New developing diffuse ground glass
which predisposes patients to benign skin
opacity and / or
tumors and renal cancer, is associated with
Consolidation superimposed on an increased incidence of PSP.
background reticular or honey comb
3. Other: Marfansyndrome, Homocystinuria.
pattern consistent with UIP pattern.
B. Secondary Spontaneous Pneumothorax (SSP)
iii. Worsening hyp onemia.
It is defined as a pneumothorax that occurs as
iv. Absence of infections, pneumonia, a complication of underlying lung disease.
sepsis and heart failure.
Etiologies
Treatment
1. Chronic Obstructive Pulmonary Disease:
i. No effective treatment 50 to 70 percent of SSP is attributed to
ii. Mechanical ventilation often required COPD. Rupture of apical blebs is the usual
iii. If patient survives - recurrence common and cause.
usually results in death. 2. Cystic Fibrosis : Usually due to rupture of

149
PRACTICAL MEDICINE

apical subpleural cysts. Factors associated C. Iatrogenic: Central line insertion, surgery,
with an increased risk of pneumothorax lung biopsy, faulty tracheostomy.
include infection with Pseudomonas IV. Artificial: It was induced in the past for severe
aeruginosa or Aspergillus species or a prior tuberculosis (At present this is obsolete because
episode of massive hemoptysis. of antituberculosis drugs).
3. Lung Malignancy : Both primary and
Types
metastatic lung malignancy have been
associated with SSP. The mechanism 1. Simple or closed Pneumothorax: The opening in
is endobronchial obstruction with air the lung is very small and heals rapidly. Therefore,
trapping. there is no continuous communication between
4. Necrot izing Pneumonia : SSP can the lung and the pleural cavity. The pleural
complicate the course of necrotizing pressure on the affected side remains sub­
pneumonia due to bacterial infection, atmospheric. A simple pneumothorax usually
Pneumocystis jirovecii, tuberculosis, and has only modest repercussions unless the
less often fungi. patient has limited respiratory reserve or is
being mechanically ventilated. Radiographically,
a. Bacterial Pneumonia : SSP has been
simple pneumothoraces tend to be small and
associated with bacterial pneumonias
without mediastinal shift to the contralateral
caused byStaphylococcus, Klebsiella,
side.
Pseudomonas, Streptococcus
pneumoni ae, a n d anaerobic 2. Open Pneumothorax : The opening between
organisms. Extension of bacterial the lung and the pleural cavity remains patent.
infection into the pleura can lead to Pressure in the pleural cavity is equal to that
development of empyema. of the atmosphere. It occurs when a traumatic
chest wall defect persists, through which air
b. Pneumocystis jirovecii : The enters the pleural space during inspiration {ie, a
pathogenesis of SSP in PCP is likely
"sucking wound"). As a result, the mediastinum
alveolar and pleural tissue invasion
shifts toward the normal side during inspiration
and rupture oflarge subpleural cysts
and the lung on the injured side remains
that are caused by tissue necrosis.
collapsed. During expiration, air exits the pleural
c. Tuberculosis : The pneumothorax is space through the chest wall defect and the
usually due to rupture of a tuberculous mediastinum swings back. Expiratory air from
cavity into the pleural space. the normal lung (ie, "pendulum air") fills the
5. Catamenial Pneumothorax : Refers to a collapsed lung. The "mediastinal flutter" may
pneumothorax occurring in association cause respiratory failure. Radiographically, an
with menses due to thoracic endometriosis open pneumothorax is characterized by a visible
6. L ess Common Causes : Ankylosing chest wall defect and by expiratory mediastinal
spondylitis, asthma, histiocytosis shift towards the injured side.
X, interstitial lung disease (eg, 3. Tension Pneumothorax : The opening between
i d i o p a t h i c p u l m o n a r y f ib r o s is), the lung and the pleural caity is "valvular" - air
lymphangioleiomyomatosis, Marfan can enter the pleural cavity during inspiration
syndrome, metastatic sarcoma, rheumatoid but cannot escape during expiration. Therefore,
arthritis, and sarcoidosis. a positive pressure (exceeding atmospheric
III. Traumatic and Iatrogenic pressure) occurs on the affected side. This
A. Penetrating wounds: Stab wounds, fractured rapidly leads to respiratory failure and a is a
ribs, crush injury. medical emergency. Radiographically, tension
B. Non-penetrating wounds: Steering wheel pneumothorax shows a distinct shift of the
impact against the drivers' chest. mediastinum to the contralateral side.

150
{ 4 Respiratory System
4. Others:
a. Pneumothorax ex vacuo : This rare type
of pneumothorax forms adjacent to an
atelectatic lobe. It is seen preferentially with
atelectasis of the right upper lobe and is
the result of rapid atelectasis producing an
abrupt decrease in the intrapleural pressure
with subsequent release of nitrogen from
pleural capillaries. Treatment consists
of bronchoscopy rather than chest tube
drainage. Radiographically, pneumothorax
ex vacuo is suggested when an atelectatic
lobe or lung, particularly right upper Fig 4 29: Bilateral pneumothorax
lobe atelectasis, is surrounded by a focal
pneumothorax. 2. Symptoms due to SSP are generally more severe
than those associated with PSP, presumably
b. Bilateral Postoperative Pneumothorax:
because patients with SSP have less pulmonary
Bilateral pneumothoraces are seen
after cardiac surgery, particularly in reserve due to underlying lung disease.
recipients of heart-lung transplants. 3. Sudden onset of dyspnea and pleuritic chest
They are a consequence of extensive pain. The severity of the symptoms is primarily
mediastinal dissection allowing a related to the volume of air in the pleural space.
unilateral pneumothorax to propagate 4. Evidence of labored breathing and hemodynamic
to the contralateral hemithorax. A compromise (eg, tachycardia, hypotension)
single thoracostomy tube is able to suggestsa possible tension pneumothorax, which
evacuate both pleural cavities. This type of necessitates emergency decompression.
pneumothorax has been dubbed "buffalo
Signs
chest;· since these animals have pleural
spaces that communicate anteriorly and, A. Closed pt1eumothorax
as a result, they are susceptible to bilateral 1. Reduced chest movement
pneumothorax . 2. Hyper-resonant note on percussion
Conditions Mimicking Pneumothorax 3. Absent air entry
l. Bullae : Large subpleural bullae can mimic 4. Mediastinal shift to opposite side
a loculated pneumothorax . Both bullae and 5. Coin Test
pneumothoraces usually have a straight or 6.-1.TVF, VR
convex pleural contour laterally, but only bullae
B. Open pneumothorax
typically have a medial border that is concave to
the chest wall. All the signs of dosed pneumothorax, plus -
2. Trauma : Herniated Stomach following trauma 1. Crackpot sound on percussion
2. Amphoric breath sounds
Diagnosis
3. Voice and cough sounds may be heard with
Symptoms metallic echo.
1. Primary spontaneous pneumothorax (PSP) C. Tension pneumothorax
usually occurs when the patient is at rest. Patients All the signs of closed pneumothorax, plus -
are typically in their early 20s, with PSP being 1. Displacement of the mediastinum with
rare after age 40. respiration

151
-
PRACTICAL MEDICINE

2. Increasing breathlessness, cyanosis and Imaging


tachycardia, tRR, ,l..ap, tTVP
I. Chest radiographs (Refer to Chapter 9)
3. Respiratory failure
Main Features :
Differential Diagnosis i. Hyper translucency between lung and
thoracic cage.
I. Table 4.11 : Differences between a
Large Pulmonary Cavity and ii. Razor sharp border of the collapsed lung
Pneumothorax (white visceral pleural line).
-
iii. Shift of mediastinum to the opposite side.
A large pulmonary Pneumothorax
cavity A pneumothorax may be identified on an upright,
1. Onset Insidious Acute supine, or lateral decubitus chest radiograph.
The lateral decubitus view tends to be the most
2. Movements Restricted or dimin· Absent on the
of chest ished at apex only or whole of the af· sensitive, while the supine view is the least
normal. fectedside sensitive.
3. TVF Increased Reduced Upright
4. Breath Cavernous/sounds Absent/am- i. Most pleural gas accumulates in an
phoric apicolateral location.
5. Coin sound Rare Present ii. The visceral pleural line appears either
6. Mediastinum Central Central/ Pushed straight or convex towards the chest wall.
iii. As little as 50 mL of pleural gas may be
U. Table 4.12 : Differences between
visible on a chest radiography.
Eventration of Diaphragm and
Pneumothorax iv. Th e colla psed l ung preserves its
t r a n s r a d i a n c y b ec a u s e hy p oxic
Eventration of Dia- Pneumothorax vasoconstriction diminishes the blood
phragm
flow to the collapsed lung.
1. Symptoms Usually absent or refer- Symptoms of
able to gastrointestinal or respiratory
Supine
circulatory system. system i. Most pleural air accumulates in a
2. Movements Increased inspiratory Movements subpulmonic location.
ascent ofcostal margin diminished on ii. Gas in this location outlines the anterior
because oflack ofop· the affected
position of paralyzed side.
pleural reflection, the costophrenic sukus
diaphragm (creating the "deep sulcus" sign), and the
3. Screening Diaphragm high in chest Radiolucency
antero\ateral border of the mediastinum
X-ray with paradoxicaI move­ seen with razor . In rare instances, pleural gas can also
ments sharp edge of accumulate in the phrenicovertebral sukus.
the collapsed
lung.
iii. The visceral pleural line may be seen at the
Jung base and has a concave contour.
Ill. Table 4.13 : Differences between iv. Approximately 500 ml of pleural gas
Congenital Large Cyst and
are needed for definitive diagnosis
Pneumothorax
of a pneumothorax on a supine chest
Congenital Pneumothorax radiograph.
Large Cyst
v. The transradiancy and size of the entire
l. Mediasti num Central To opposite side hemithorax may be increased on the side
2.X-ray No collapsed lung at Collapsed lung at of a pneumothorax.
hilum. hilum vi. A hydropneumothorax in a supine patient

152
NE , 4 Respiratory System

can produce a veil-like opacity, more With the patient in sitting position, a
opaque than a pure pneumothorax and Needle ( 14 guage) is inserted into the
less opaque than a pure hydrothorax . pleural cavity in the second space in
Lateral decubitus the mid-davicular line or in the fifth
nd space in the axillary line. The other
i. A pneumothorax can be most easily
detected with a lateral decubitus view. In end of the needle is connected to the
ng this position, most pleural airaccumulates underwater seal.
in the non-dependent lateral location. 2. If there is no cardiorespiratory embarrasment
le. ii. The visceral pleural line appears either a. If pneumothorax is small (:::;: 3 cm between
lt, straight or convex towards the chest wall. lung and chest wall): Supplemental oxygen
h. iii. As little as 5 mL ofpleural air may be visible and observation.
st on a lateral decubitus chest radiograph. b. If pneumothorax is large(> 3 cm between
,t 2. Computed Tomography lung and chest wall):
This is the most accurate imaging modality for i. Needle Aspiration.
the detection of pneumothorax. Even small ii. Tube Thoracostomy (Chest Tube
11 amounts ofintrapleural gas, atypical collections Insertion) : if needle aspiration fails.
ofpleural gas, and loculated pneumothoraces can iii. Thoracoscopy (VATS): See below.
be identified by CT. In addition, complex pleural
pathology (eg, pleural effusion, pneumothorax) iv. Chemical Pleurodesis : If air leak
can be optimally displayed by CT scanning. persists.
Pleural interventional procedures are also c. Re c urren t Pne umot ho rax
facilitated by CT guidance. Hydropneumothorax : Chest Tube
insertion and Thoracoscopy. Chemical
3. Ultrasound : Ultrasound of the chest is
Pleurodosis may be performed.
sometimes used to evaluate situations in which
the diagnosis must be made emergently at the Supplemental oxygen : administered to facilitate
bedside, such as an ICU patient or a trauma resorption of the pleural air.
patient in the emergency department, so-called Aspiration : Aspiration is most easily accomplished
point-of-care ultrasound. with a commercially available thoracentesis kit. Once
In the presence of a pneumothorax, smooth, no more air can be aspirated, the catheter can be
horizontal echogenic lines are seen above and removed or left in place attached to a one-way valve
below the pleural line and there is absence of (Heimlich Valve).
lung sliding and B lines. Tube thoracostomy : Chest tube (:0:22 Fr) or chest
Treatment catheter (:514 Fr) is connected to a water seal device,
with or without suction and left in position until the
Initial management is directed at removing air from the pneumothorax resolves. The chest tube can be removed
pleural space, with subsequent management directed if the pneumothorax has not reaccumulated.
at preventing recurrence.
Thoracoscopy: Video-assisted thoracoscopy (VATS)
Initial management: The choice ofprocedure depends
-With this procedure, pleurodesis is created by pleural
on patient characteristics and clinical circumstances:
abrasion or a partial parietal pleurectomy; when neces­
l. If cardio-respiratory embarressment: sary, an endoscopic stapler can be used to resect bullae.
a. Supplemental oxygen Persistent air leak : A more aggressive approach is
b. Treatment of shock needed if an air leak persists after three days. For
c. Aspiration of pneumothorax: patients whose lung has expanded >90%.
Chest Tube Inser tion (Tube A Heimlich valve can be attached to the chest
Thoractostomy) or tube.

153
PRACTICAL MEDICINE
Autologous blood or tube can be infused into 2. Hydatid Cysts
the pleural space for chemical pleuradesis 3. Fungal infection
• Performing video-assisted thoracoscopy to 4. Abscess
oversew the area of leak and perform mechanical B. Neoplasms
pleurodesis.
l. Bronchogenic carcinoma
Failure of lung reexpansion : For patients who have
2. Metastasis
a persistent air leak and whose lung is less than 90
percent expanded, the preferred procedure is VATS. 3. Lymphoma
Recurrence prevention C. Traumatic: Resolving hematoma
a. Pleurodesis via VATS orchemical pleurodesis via D. Congenital
tube thoracostomy (talc, bleomycin, tetracyclin l. Infected bronchogenic cyst
derivatives like doxycycline or autologus blood 2. Sequestration
can be used). E. Immunological
b. Thoracotomy : T he indications for open 1. Rheumatoid
thoracotomy are the same as those for VATS.
Thoracotomy is presently recommended only if 2. Wegener's granulomatosis
thoracoscopy is unavailable or has failed. During F. Vascular: Pulmonary infarction
thoracotomy, apical pleural blebs are oversewn On CXR 3/4'h of circumference should be well
and the pleura is scarified. defined in order to call it a cavity.
C. Smoking cessation: may help prevent recurrent Table 4.13 : Types of Pulmonary Cavities
pneumothoraces. Thin shaggy walled Thin smooth waited Thick walled

Tuberculosis Tuberculosis Bronchogenic


7 Pulmonary Cavity Lung abscess Lung cyst carcinoma
Definition: Pulmonary cavity is an area ofliquefaction Bronchogenic card- Emphysematous Lung abscess
noma bullae
necrosis within the lung parenchyma in communica­
tion with the bronchus. The cavity may remain empty Hydatid cyst
or may be filled with secretions or infected material. Fungal infection
Pseudo cavity is appearance of a cavity radiologically Table 4.14 : Diagnosis of Pulmonary
which may be obtained with summation shadows of Cavities
vessels, ribs and calcifications. Empty Fluid filled
Causes 1. Movements over apex Diminished Diminished
A. Infection 2. Retraction/Flattening Present Present
1. Tuberculosis of chest
3. TVFNR Increased Decreased
4. Percussion note Crack-pot sound Diminished
5. Breath sound Amphoric/ Diminished
Cavernous
6. Whispering pectorilo- Present Absent
quy
7. Post tussive rales Absent Present
X-ray Chest: Ring shadows

154
( 4 ) Respiratory System

8 Bronchogenic
Carcinoma
Bronchogenic carcinoma must be considered in all
cases, esp. > 40 years, or smokers presenting with
respiratory involvement particularly with signs of:
I. Collapse
II. Consolidation
III. Cavitation
IV. Mediastinal obstruction
V. Pleural effusion
VI. Apical dullness, wasting of upper limb and
Horner's syndrome
Table 4.1 S : Differences between various
types of Bronchogenic Carcinomas
Epider- Adeno- Anaplas- Alveolar
moid carcino- tic cell
mo Fig 4 32 X ray chest 1n a case ofllronchogen1l carcinoma
showing collapse L upperlobe,v,th d1>sen11nated
1. Situation Central Periph- Either Both
metastasis I
eral -- --- - -�- ---

2.Spread Byconti- By all Byall Broncho·


nuity routes, routes genie and
especially especially byconti-
blood blood nuity
3.0nset Early Late Early Early
4. Association Cigarette Focal
smoking lung scars
S.Sex Males Females Males Females

Fig 4 33 Broc•>oge.-,,ccarc,roriasl1ow ng 'lOdu'ar


opacity on the right s1cie
----- -- ------ -

Types of Bronchogenic Carcinoma


l. Squamous cell or epidermoid carcinoma.
2. Adenocarcinoma
3. Anaplastic

I _ _ _ __ F1�4, 1 Pancoast tumour


_____ ._
4. Alveolar cell carcinoma

155
PRACTICAL MEDICINE

Symptoms IV. Due to Metastasis:


The patient may present with no symptoms, or the A. Lymphatic: To mediastinal, cervical and
following symptoms: axillary glands
I. General: Fever, malaise, anorexia, weight loss
B. Hematogenous: To brain, liver, skin,
and weakness. subcutaneous tissue, muscle, bone and
breast
II. Respiratory:
C. Bronchogenic: In the sameor opposite lung
A. Cough with/without mucopurul ent
V. Paraneoplastic or Non-metastatic
sputum.
Manifestations
B. Hemoptysis
A. Endocrine
C. Breathlessness I. Cushing's syndrome (excess ACTH)
D. Stridor 2. Hyperca\cemia (excess PTH)
E. Chest pain of various types: 3. Hyponatremia (excess ADH)
1. Pleuritic due to localized pneumonia 4. Hypoglycemia (excess insulin-like
or carcinomatous involvement of substance)
pleura 5. Carcinoid (excess serotonin)
2. Persistent severe radiating along the 6. Polycythemia ( excess erythropoietin)
distribution of the intercostal nerves
7. Gynecomastia (excess sex hormone)
III. Due to Local Spread:
B. Skeletal: Clubbing
A. Nerves:
C. Skin
1. Phrenic: Hiccoughs, Paresis of 1. Acanthosis nigricans
diaphragm
2. Pruritus
2. Recurrent laryngeal: Hoarse voice,
3. Eczema
bovine cough
D. Neurological
3. Sympathetic: Homer's syndrome
I. Neuropathy
4. Vagus: Gastric symptoms
2. Amyotrophy
5. Brachia! plexus: Weakness, wasting
3. Myelopathy
and sensory impairment over the
ulnar border ofthe forearm and hand 4. Encephalopathy
6. Intercostal nerves E. Muscular
1. Polymyositis
B. Esophagus: Dysphagia
2. Dermatomyositis
C. Blood vessels:
3. Myasthenia
I. Superio r vena cava: Venous
engorgement of head and neck F. Vascular:
2. Azygous vein: Dilated veins over chest 1. Thrombophlebitis migrans
wall 2. Non-bacterial endocarditis
3. Axillary vessels: Loss of peripheral G. Hematological:
pulsations and edema of the arm I. Hemolytic anemia
D. Thoracic duct: Chylous effusion 2. Thrombocytopenia
E. Erosion of ribs: Local pain and tenderness
Predisposing Factors
Invasion of heart and pericardium: CCF,
arrhythmias, pericardia! effusion. 1. Cigarette smoking

156
( 4 > Respiratory System

2. Occupational exposure to chromium, arsenic, Treatment


nickel, coal gas, beryllium, iron and iron oxides
Curative treatment is achieved by surgical resection.
3. Air Pollution If the tumour has spread, palliation can be achieved
4. Radiation by radiotherapy and chemotherapy.
5. Chronic scarring I. Surgery
Few patients are treatable by surgery. Even if the
Radiology
tumour is localized, results of surgery are poor
1. There may be no radiological abnormality. in undifferentiated and poorly differentiated
2. Unilateral enlargement of hilar shadows. tumours, whereas in squamous cell carcinoma
5-year survival is as high as 50%.
3. Peripheral shadows: Nodular and irregular
homogenous or non-homogenous densities. Before surgery, staging of the tumour and
pulmonary function tests (PFT) should be
4. Due to complications:
done. If PFT is poor there is high risk of post­
a. Cavity, collapse or consolidation. operative complications and surgery is usually
b. Pleural or pericardia! effusion. not considered.
c. Unilateral elevation of diaphragm. II. Radiotherapy
d. Pathological fracture of rib. It is not curativ�, but useful to relieve
distressing complications like superior vena
5. Thoracic inlet tumour:
cava obstruction, hemoptysis and pain caused
a. Dense irregular crescent at the apex. by chest wall invasion or skeletal metastasis.
b. Destruction of the first three ribs. Undifferentiated and poorly differentiated
c. Bilateral hilar enlargement. tumours are more susceptible to radiotherapy.
d. Lymphangitis carcinomatosis. III. Chemotherapy
Combination chemotherapy of 6 cycles at 3
Useful Investigations weeks interval consisting of the following drugs
1. X-ray and CT scan of chest is useful:
l. Doxorubicin 60 mg/sq.m. IV bolus- Day I
2. Bronchoscopy and mediastinoscopy
2. Cyclophosphamide 750 mg/sq.m. IV
3. Lung scan
infusion- Day I
4. Sputum cytology
3. Etoposide 120 mg/sq.m. IV infusion •
5. Scalene node biopsy Day l
6. Lung biopsy They are useful in good prognosis group of
7. Tapping and examination of fluid - if there is patients (Age <70 years, Normal albumin and
pleural effusion. sodium and weight loss <10%).
In poor prognosis group, oral etoposide, 50 mg
Cavity with:
Irregular
12 hourly for 10 days every 3 weeks for 6 cycles
margins lymphaclenopathy offers good palliation.
un<l
Air­ In general, chemotherapy is less effective in
nui<l non-small cell bronchial carcinomas.
level
IV. Laser therapy
Hilar Laser therapy via fiberoptic bronchoscope
lymphadeno·
pathy
destroys the tumour tissue occluding the main
bronchi and allows re-aeration of collapsed lung.
Fig 4 34 Rad1olog1cal appearances 1n bronchogen1c
carcinoma
It is essentially palliative.

157
PRACTICAL MEDICINE

called the PRIMARY COMPLEX (Ghon'sComplex}.


9 Pulmonary Tuberculosis In the first few months following the primary infection,
Tubercle bacilli gain entry into the body usually by the tubercle bacilli can enter the lymphatics and from
inhalation or ingestion. Rarely they may gain entry there the blood stream via the thoracic duct. Usu­
through the skin, tonsils, conjunctiva and external geni­ ally primary infection is seen in infants or children.
talia. Sputum of the infectious patient is the commonest Younger children have greater chances of progression
source of tubercle bacilli. The bacilli are scattered in of tuberculosis and developing its complications.
the atmosphere mainly by coughing. (A single cough
expels up to 40,000 tubercle bacilli). Droplets of sputum Primary Complex Consists of:
containing the bacilli may be inhaled directly by those I. Subpleural TB
in the vicinity or they may fall on the ground and mix
2. Hilar Lymphadenopathy
with dust. When the ground is swept, the bacilli rise
with the dust and may be inhaled. A sputum positive 3. Draining Lymphatics
patient infects upto 25 persons / year. 4. Right middle lobe collapse (Brock's syndrome):
rare and seen mainly in children.
Primary Pulmonary Tuberculosis
Pathogenesis: On inhalation, the tubercle bacillireach Classification
the respiratory bronchioles and alveoli where they are I. GHON'Sfocus - subpleural (lung)
taken up by the macrophages. These macro-phages 2. Ashman's focus - deep apical ( lung)
may carry the tubercle bacilli elsewhere. Within the
3. Simmons focus - subpleural upper lobe focus
macrophages, the tubercle bacilli may multiply.
4. Cerebral - Rich's focus
After about 3-8 weeks the individual develops a hy­
persensitivity to tuberculoprotein through specific 5. Blood vessel - ([ntima) Wigard's focus
modification of thymus dependent lymphocytes. At 6. Liver - Simmonds focus
this time the following changes occur: 7. Primary splenic, intestinal, primary lymph node
1. Tuberculin test becomes positive. focus.
2. Macrophages may rupture releasing tubercle
bacilli. Fate of Primary Complex
3. Granulomatous lesion (tubercle) may form. I. rt may heal completely with or without
It consists of: calei Ii.cation.
a. Epithelioid cells derived from macrophages. 2. It may remain dormant, reawakening when the
b. Langhans giant cells also derived from body defenses decrease.
macrophages.
c. Lymphocytes.
d. Central caseation due to cheesy type of
necrosis: Caseous tissues may liquefy to
become purulent material, which may be
discharged into the air spaces, or it may be

l
C::.Olcifi<:.01ion
calcified. :/ / \ '-
Sequclae to
Pulmonary TB
8
A number of such tubercles may merge to form an l'ocu0.J'
and �
)-.,
1
,J
(

area of pneumonitis ( which is commonly subpleural). llilnr-1-,--..,


nodus J f "
The lymphatics draining this area of pneumonitis may
become involved and a chain of tubercles may be seen �
along these lymphatics going towards the hilar lymph
nodes, which also becomecaseousand enlarged. This is

158
{ 4 ) Respiratory System

3. It may actively progress merging into post· density involving complete lobe yet the
primary pulmonary tuberculosis. general condition of the patient is good.
4. It may lead to hematogenous spread of tubercle Prognosis is excellent. It may be due to
bacilli leading to miliary tuberculosis or inflammatory exudate, collapse or caseous
tuberculous meningitis. pneumonia.
Clinical Features 2. Bronchiectasis
A. Symptoms 3. Obstructive emphysema
1. There may be no symptoms 4. Pleural effusion
2. Fever for a brief period, which is often B. Allergic
passed off as influenza. Evening rise of I. Erythema nodosum
temperature. 2. Phlyctenular conjunctivitis
3. Anorexia and weight loss
C. Due to hematogenous spread
4. Cough and wheeze due to pressure oflymph
I. Miliary tuberculosis
nodes on bronchi
B. Signs 2. TB meningitis
1. There may be no detectable physical sign. 3. Tuberculosis of bone, joints, kidneys and
2. General debility: A thin, pale, fretful child skin, any organ.
with loss of skin elasticity and less glossy Post-primary Pulmonary Tuberculosis
hair. Pathogenesis
3. Local areas of rales or rhonchi.
C. Radiology Post-primary pulmonary tuberculosis may
In adults the pulmonary component is more rise in any one of the four ways:
obvious, whereas in children the glandular 1. Direct progression of primary lesion
component is more obvious.
2. Reactivation of the primary lesion when the
Radiological findings are: individual's defenses have waned
1. Soft confluent shadow (suggesting
3. Hematogenous spread of the disease from the
exudative process)
primary focus
2. Linear shadow (suggesting fibrosis)
4. Exogenous superinfection with drug resistant
3. Cavity: Initially irregular, later smooth
bacilli.
walled
4. Thin walled bullae The lesions of reinfection have the same basic tubercu­

-
lar pathology. Hyperallergy and immunity acquired as
5. Blocked cavity
a result of first infection exert two opposing influences.
6. Calcification
As a result of hyper allergy there is a considerable tis­
7. Bronchiectasis especially in the upper zones sue destruction and as a result of immunity there is a
8. Bronchial cold abscess: Elongated solid constant attempt at healing by localization and fibrosis.
dense shadow There is no tendency ofinvolvement of draining glands.
9. Enlarged hilar nodes When the immunity is high, exudative lesions are re­
10. Miliary mottling placed by fibrotic lesions giving a nodular appearance.
11. Tuberculoma The lesions spread along the peribronchial lymphatics
12. Primary complex giving a typical X-ray appearance of infiltration - patchy
opacities interspersed with normal parenchyma. In
Complications
healing, the peribronchial granulation tissue is replaced
A. Pulmonary: by fibrosis, which leads to dilatation of bronchi by
I. Epituberculosis: Dense homogenous traction (post-tuberculous bronchiectasis).

159
PRACTICAL MEDICINE

When immunity is low and the tempo of activity high, chest or there may be signs of pleural effusion.
tuberculous material may be aspirated through the pneumothorax, hydropneumothorax, consoli­
bronchi into other parts of the same or the opposite dation, collapse, fibrosis or cavitation. Some­
lung producing fresh lesions. The caseous material times the only sign present may be localized
liquefies and discharges into a bronchus so that a cavity rhonchi or post tussive rates especially at the
forms. Cavity is a favorable breeding ground for the apices.
tubercle bacilli. (Caseous material has l x 10·1 bacilli Table 4.16 : Differences between
/ gm, Cavity has 1 x 10�). Progressive Primary Complex and Post­
The common sites of tuberculous lesion are the poste­ primary TB
rior segment of the upper lobe or the apical segment of Progressive Primary Com- Post Primary TB
the lower lobe. This is mostly due to decreased blood plex
flow and relatively good ventilation of the upper lobe 1. Increased Hilarlymph node 1. Absence of lymph node
in the upright position. (usually)
2. Primary complex in any part 2. Usually apical fibrosis
Clinical Features
of the lung

Symptoms 3. Benign course, rarely cavita- 3. Tends tocavitate and


lion, fibrosis is common progression common
I. Due to toxemia: General symptoms such as 4. MiliaryTBcommon 4. MiliaryTB uncommon
fever with evening rise of temperature, night
5. DisseminatedTB
sweats, anorexia, weight loss, tiredness and
mental symptoms like irritability and difficulty
Stigmas of TB: (evidence of present or past infection
in concentration.
or disease)
2. Local symptoms: These are caused by the disease
l. Phlyctenular conjunctivitis
process in the lungs. The symptoms include
cough with expectoration, pleuritic chest pain 2. Erythema Nodosum: Erythematous raised
breathlessness and hemoptysis. subcutaneous nodules, painful, te nder,
seen on lower limb.
3. Indirect symptoms: Indigestion and dyspepsia
due to stimulation of parasympathetic fibers. 3. TB Lymphadenopathy: With or without scars
Amenorrhea often occurs in a young womaneven and sinuses.
without direct involvement of the reproductive 4. Thickened, beaded spermatic cord
organs. 5. Mantoux Test
4. Symptoms from complications 6. Scrofuloderma (skin TB)
5. Due to primary/associated disease e.g. diabetes 7. Localized gibbus, spinal deformity, paravertebral
mellitus, HIV infection, alcoholism, COPD, soft tissue swelling.
immuno-suppressed individuals, patients on
cortico-steroid therapy Investigations
6. Psychological: Anxiety neurosis, night sweats I. Laboratory Investigation
7. Hemoptysis due to rupture of a hypertrophied 1. CBC: Anemia & leucocytosis: (Lymphocytes
bronchial vessel (Rasmuscn's aneurysm). > 75%. In treated TB, eosinophils increase.
Signs In miliary TB, neutrophils increase.
2. ESR raised (non specific)
l. Due to toxemia: Fever, tachycardia, tachypnea,
loss of weight, loss of elasticity of skin and 3. Mantoux Test (Tuberculin test in select
clubbing in chronic cases with purulent sputum. cases)
2. Local signs: There may be no local signs in the 4. ADA (Adenosine Deaminase) levels
increased

160
( 4 ) Respiratory System

F,g.4.37 .Tuberculous 1nfiltrat1on right apex with left sided


pneumothorax

5. Specimen Microscopy
a. Traditional method - Ziehl-Neelson
6. Culture Techniques
Stain.
a. Conventional methods
b. Can detect upto 70% ofculturepositive
samples with lower limit of detection i. Agar based media takes 10 12
of 5 x 103 organisms / ml. days.
c. Modifications include ii. Egg based Lowenstein Jensen
i. Use of Bleach Medium takes 18-24 days.
ii. Us e o f G u a n i d i n i u m More sensitive than smear examination
Hydrochloride and allows for biochemical identification
of species enhancing specificity.
iii. Fl uorescent M i c r oscope -
Auramine and rhodamine stains. b. Automated Liquid Culture Method:
d. WHO 2010 guideline : Only two i. Mycobacterial Grower Indication
sputum sspecimens required. One Tube (MGIT) 960 TB
sample should be an early morning Employs fluorescent technology
sample. that enables result in 7-10 days.

161
PRACTICAL MEDICINE

Used for isolation and accurate Various PCR assays include


identification of mycobacteria. I. PolymeraseChainReaction (PCR)
Employed for identification of : amplifies specific DNA sequence.
culture positive isolates - PNB Nested PCR enhances sensitivity
(para-nitro benzoic acid) of PCR
ii. MB Bactis based ona Colorimetric 2. Tr a n s c ri p t i o n M e d i ated
CO 2 sensor that is altered by Amplifications (TMA) : Uses
bacterial metabolism. specific sequence of ribosomal
RNA (rRNA) as target of reverse
[Liquid culture systems when
transcriptase. [False Positive
combined with DNA probes
reports are a concern. Presence of
or MPT 64 detection, produce
an organism in a clinical specimen
positive results in 2 weeks for
does not necessarily indicate
sputum smear positive patients
disease]
and 3 weeks for smear negative
specimens) B. Molecular Methodsfor detecting drug
resistant TB:
7. Immunologic Methods
I. Genotypic Methods:
I. Serological methods : Have poor
a. Soid Phase Hybridization
sensitivity and specificity in endemic techniques: Line Probe Assays
areas. WHO 2011 had issued a for detection of resistance to
negative policy recommendation
rifampicin. Genotype MTBDR
in July 2011 for the use of any
assay for detection of resistance
commercial serological assay in the to Isoniozid and Rifampicin.
diagnosis of active tuberculosis.
b. Real Time PCR technique.
2. Interferon Gamma Release Assay 2. MolecularBeacon Assays - based
(IGRAs): on a stem and loop structure with
Used for diagnosis of latent TB. loop in the probe.
Antigens used - Early Secretory 3. Microassays - also known as
Antigenic Target - 6 (ESAT - 6) and Biochips or DNA chips.
Culture Filtrate protein - 10 (CFP -
9. Drug Susceptibility Tests (DST)
10).
A. Phenotypic methods
Quanti FERON GOLD assay - uses
l. Absolute concentration method
both ESAT - 6 and CFP-10; Whole
2. Resistance Ratio Method
blood is used.
3. Proportion method
T-SPOT TB - uses peripheral blood
Standard methods require 3-6
mononuclear cells (PBMC's) and
weeks to report a susceptibility
detects the number of"spot forming T
test from a positive culture.
cells" by use of ELISPOT in response
to above antigens. BACTEC MGIT 960 l %
propor tion method is Gold
WHO 2011 had issued policy that
standard for drug susceptibility
/GRAS should not be usedfor diagnosis
testing for first line drugs.
of Active TB.
Recently critical concentration
8. Molecular Techniques methods for second line drugs
A. Direct detection from clinical samples have also been tested successfully
by Nucleic Acid Amplification. for most drugs.

162
( 4 l Respiratory System
4. Direct Rapid Methods for screening Complications
MDR-TB:
l. Dry pleurisy, pleural effusion or empyema
a. Nitrate Reduction Assay (NRA):
Based onabilityofM. tuberculosis 2. Chronic bronchitis and laryngitis
to reduce Nitrate to Nitrite. 3. Cor-pulmonale
b. Microscopic observation broth, 4. Aspergillosis
drug susceptibility assay: Based 5. Amyloidosis
on observation of characteristic 6. Anemia
cord formation ofM. tuberculosis
7. Tuberculosis of other organs
is complex that is visualized by
inverted microscope. Treatment
c. Thin Layer Agar (TLA) : I. Bed rest in a Sanitorium/ Hospital: In the past,
ShortTurn around timeofl l days. pleasant rural or mountainous surroundings,
Microscopic Examination of fresh air, good food and graded exercises were
growth on solid media using the only modes of therapy. With chemotherapy,
TH 11 Middle Brook agar in the results are as good without bed-rest as with
quadrant petri plates containing it. However bed rest is advised for the following:
isoniazid, rifampicin, PNB and 1. Very ill patient with extensive disease
one without additive. 2. Infectious cases with sputum positive for
Indications of DST: AFB or very extensive disease radiologically.
1. Ideally should be done in all cases ll. Chemotherapy:
prior to start of Anti TB Rx. Classification of Antitubercular drugs
2. For definite diagnosis Bacteriocidal : Isoniazide, Rifampicin,
a. All previously treated cases. Streptomycin, Pyranzinamide
b. All cases of HIV with active TB Bacteriostatic : Ethambutol, Thiacetazone,
c. Developing activeTB after contact Par a-amin o s alic ylic acid (PAS),
with MDR TB cases. Ethionamide.
Case definitions (WHO Guidelines 2010)
d. All new cases in an area where
level of MDR cases is >73% (In l. Tuberculosis suspect:
India it is< 3%). Any person who presents with symptoms
e. Treatment failure cases or signs suggestive of TB.
10. Bronchoscopy- trans thoracic aspiration 2. Case of Tuberculosis
BAL. A definite caseofTB orone in which a health
11. Scalene Lymph Node Biopsy worker has diagnosed TB and has decided
to treat the patient with a full course ofTB
12. Lung Biopsy treatment.
II. Imaging 3. Definite Case of Tuberculosis
1. X-ray chest: AP, PA, Lateral, Lordotic- to A patient with Mycobacterium Tuberculosis
see apical area of lung complex identified from a clinical specimen,
2. Fluoroscopy- outdated either by culture or by a newer method such
3. Bronchography as molecular line probe assay.
4. CT Scan a. New Patients : New patients have never
had treatment for TB, or have taken anti­
5. MRI
TB drugs for less than one month.

163
PRACTICAL MEDICINE

b. Previously treated patients : Previously or


treated patients have received one month If HIV - negative no improvement
or more of Anti-TB drugs in the past, may in response to a course of blood
have positive or negative bacteriology and spectrum antibiotics (excluding anti­
may have disease at any anatomical site. TB drugs and Fluocoquinolones and
c. Relapse : Patients who have been cured Aminoglycosides).
previously from or completed treatment Previously TB patients were grouped under categories
for TB and now have TB. I -IV. The new grouping has been based on likelihood
d. Failure : A patient whose sputum smear of patients having drug resistance which is a critical
or culture is positive at 5 months or later determinant in deciding treatment. Prior TB treat­
during treatment. Also included are ment confers an increased risk of multi drug resistant
patients found to have a multidrug-resistant tuberculosis.
(MDR) strain at any point of time during
the treatment, whether they are smear - Treatment of New Patients
negative or smear positive. Table 4.17 : Recommended doses of
e. Default : A patient whose treatment was First-Line Anti Tuberculosis drugs
interrupted for two consecutive months or
Recommended Dose
more.
f. Cured : A patient whose sputum smear or
culture was positive at the beginning of the
treatment but who was smear or culture -
negative in the last month oftreatmentand
on atleast one previous occasion. 5(4-6)
lsoniazid 300 10(8-12) 900
g. Treatment Completed : A patient who Rifampicin 10(8-12) 600 10(8-12) 600
completed treatment but who does not
Pyrazin- 25 (20-30) - 35 (30-40) .
have a negative sputum smear or culture amide
result in the last month of treatment and
Ethambu- 15 (15-20) - 30 (25-35) .
on at least one previous occasion. tol
h. Treatment success : A sum of cured and Strepto- 15 (12-18) 15 (12-18) 1000
completed treatment. mycin
i. Smear Positive Pulmonary TB : Based on
Table 4.18 : Regimen for treatment of TB
the presence ofat least one acid fast bacillus
(AFB+) in atleast one sputum sample. Category of cases Intensive Phase Continuation
Phase
j. Smear Negative PTB cases should either
New Cases 2 months of HRZE 4 months of HR
A. Have sputum that is smear negative but
Previously Treated
culture - positive for M. tuberculosis:
Cases
OR • Failure cases Em perical M DR 18-24 months
B. Meet the following criteria (High Likelihood regimen for6-9
ofMDR-TB) months (modified
i. decision by a clinician to treat with a
after DST result)
full course of anti - TB therapy; and
Relapse/Default 2HRZES/1 HRZE
ii. radiographic abnormalities consistent (Medium/ Low / 5HRE(modified
with active pulmonary TB and Likelihood of after DST results)
MDR-TB)
either
Laboratory or strong clinical evidence Standard Regimen
of HIV infection The 2 HRZE / 4HR is the standard regimen where

164
< 4 ) Respiratory System
isoniazid (H), Rifampicin (R), Pyranzinamide (Z) b. P/H of Acute Viral Hepatitis
and Etahmbutol (E) are given for 2 months (Intensive c. Currentexcessivealcoholconsumption
Phase). This is followed by HR for4 months (Continu­ [Hepatotoxic reactions are more
ation Phase). Daily regimen during both phases is common].
optimal. However alternative regimen with dosing 3
B. Unstable or Advanced Liver disease I ALT
times per week is acceptable if administered via DOTS
� 3 times ULN following regimens used
(Directly Observed Therapy - Short Term).
a. Two Hepatotoxic drugs
In settings where the level of lsoniazoid resistance
among new TB cases is high and isoniazid susceptibil • 9 months HRE
ity testing is not done before the continuation phase 2 mths HRSE followed by 6 mths
begins, following regimen is given: Intensive Phase - 2 of HR.
HRZE and Continuation Phase 4 HRE. 6 • 9 mths of RZE.
Treatment of Extrapulmonary TB (EPTB) b. One Hepatotoxic drug
A. HIV Testing is important in patients with or 2 mths of HES followed by 10
suspected of having EPTB. months of HE.
8. EPTB is treated with same Regimen as for c. No Hepatotoxic drugs
Pulmonary TB except 18 - 24 mths of STM, ETB and
9· 12 monthsoffreatment for TB meningitis Fluoroquinolone.
(because of risk of severe disability and
3. Renal Failure and severe renal insufficiency:
mortality}.
Regimen - 2 mths of HRZE followed by 4
9 months of treatment for TB ofBones and
mths of HR [No dose adjustment of H&R
joints (because of difficulties in assessing required as they have biliary excretion.
treatment response). There is significant renal excretion of ETB
C. In TB meningitis Ethambutol should be replaced and metabolities ofPZA so dose adjustment
by streptomycin. is required].
Tretment Regimens in special population [STM avoided as there is increased risk of
l. Pregnancy and Breast Feeding ototoxicity).
A. With the exception of streptomycin, first Note : All patients receiving Isoniazide, should receive
line Anti TB drugs are safe [STM is ototoxic pyridoxine supplementation to prevent peripheral
to thefetusI neuropathy.
B. No contraindication for Breast feeding. Management of Previously Treated Patients
Should continue with full course of AKT. Previous TB treatment is a strong determinant of drug
C. After active TB in the baby is ruled out, resistance and previously treated patients comprise
baby should be given 6 months oflsoniazid 13% of the Global TB.
preventive therapy, followed by BCG Drug Resistant Tuberculosis is defined as a case of
vaccination. tuberculosis who are excreting bacilli resistant to one
D. P yr i d o x i n e s u p p l e m ent a t i o n i s or more anti-tubercular drugs.
recommended fo r all pregnant or breast Multidrug Resistant - TB (MDR - TB) is defined
feeding women taking isoniazid. as disease due to M. tuberculosis that is resistant to
2. Liver disorders Isoniazid and Rifampicin with or without resistance
A. Usual regimen can be given to following to other drugs.
patients provided that there is no clinical XDR -TB: MDR strains that are resistant to all fluo­
evidence of chronic liver disease roquinolones and to atleast one of three second line
a. Hepatitis virus carriers injectable agents.

165
PRACTICAL MEDICINE

Table 4.19 : Standard Regimens for 2. Ifsmear positive at month 3, obtain culture
Previously Treated Patients and DST.
Drug Sensitivity Likelihood of MDR 3. Smear or Culture positivity at the fifth
Testing month or later ( or detection ofMDR T B
Likelihood of MOR High (Failure) Medium or low at any point) is defined as treatment failure
(Relapse. Default) and necessitates re-registration and change
Conventional While awaiting DST Results: of treatment.
method C. New Pulmonary TB patients whose sputum smear
DSTAvailable EmpiricalMDR" 2HRZES/1 HRZE microscopy was negative at start of treatment.
Regimen. (Regimen /5 HRE (Regimen
modified once DST modified once 1. Recheck sputum smear at end of2 months
resu Its are avail- DST results are and if negative, no further sputum
able) available) monitoring is required.
DSTNotAvailable EmpiricalMDR. 2HRZES/1 HRZE 2. Clinical monitoring is more importnat -
Regimen / 5 H RE for full
course ofRx Body Weight is the most useful indicator.
(Regimen should be modified once D. Extra Pulmonary TB
DST results or DRS data are available) Clinical monitoring is more importnat - Body
*Emperital MOR Regimen :Refer Pg. 167 Weight is the most useful indicators.
Drug SensitivityTesting (DST): Rapid Molecular based Management of drug - induced hepatitis
methods with results available in 1-2 days to confirm /
H, R, Zcan all cause liver damage. Rifampicin can cause
exclude M DR-TB and guide choice ofre g imen
asymptomatic jaundice without evidence ofhepatitis.
Management depends on
Mono Resistance TB is defined as resistance to one
Anti-tuberculosis drug. a. Whether patient is in intensive or continuation
Poly Resistance TB is defined as resistance to more phase.
than one Anti tuberculous drug. b. Severity ofliver disease
Monitoring during treatment c. Severity ofTB
To Ensure cure, compliance. To monitor side effects d. Capacity of Health Care Unit to manage side
A. Sputum smear microscopy in New Sputum Positive effects.
Pulmonary TB patients: Treatment
1. For smear positive pulmonary TB patients l. All drugs should be stopped. Ifpatient is severly
treated with first line drugs, sputum ill, non-hepatotixc regimen of streptomycin,
smear microscopy may be performed at ethambutol and fluoroquinolone should be
completion ofintensi ve phase oftreatment. started.
2. Ifsmear -positive at month 2, {i.e. intensive 2. It is necessary to wait for LFT to revert to
phase) obtain sputum smear again at month normal and clinical symptoms to resolve before
3. If smear remains positive at month 3, re-introducing anti-TB drugs. Ifnot possible to
obtain culture and DST. perform LFT, advisable to wait for extra 2 weeks
3. Smear or Culture positivity at the fifth after resolution ofjaundice and upper abdominal
month or later ( or detection ofMDR - TB pain/ tenderness before restarting TB treatment.
at any point) is defined as treatment failure
3. If hepatotoxicity does not resolve, non
and necessitates re-registration and change
hepatotoxic regimen consisting of STM, ETB,
of treatment.
FQ given for 18-24 months.
B. Sputum smear microscopy in previously treated
patients. 4. 0 need rug induced hepatitis has resolved, drugs
1. Smear is obtained at end oflntensive Phase are reintroduced one at a time. If symptoms
i.e. at month 3. recur or liver function tests become abnormal as

166
( 4 > Respiratory System
the drugs are reintroduced, the last drug added Table 4.20 : Groups of Drugs to treat
should be stopped. It is advised to start with MOR-TB
Rifampicin because it is less likely than H or Z
Group Drug
to cause hepatotoxicity and is the most effective
agent. After 3-7 days H may be reintroduced. Group 1 Pyrazinamide (Z)
First Line Oral Agents Ethambutol (E)
5. Alternative regimen depending on drug Rifabutin (Rfb)
implicated:
Group2 Kanamycin (KM)
a. If 'R' is implicated : 2 months of SHE Injectable Agents Amikacin (AM)
followed by 10 months of HE. Capreomycin (CM)
b. Jf'H' is implicated: 6-9 months of RZE. Streptomycin (S)

c. If'Z' is implicated: 9 months of HR. Group3 Levofloxacin (Lfx)


Fluoroquinoles Moxifloxacin (Mfx)
d. If neither R or H can be used: 18-24 mths Ofloxacin (Ofx)
STM, ET and tluoroquinotine.
Group4 Para-aminosal icytic acid (PAS)
6. When hepatitis with Jaundice occurs during the Oral bacteriostatic Cycloserine (CS)
intensive phase of TB treatment with HRZE - Second-tine agents Terizidone (Trd)
once hepatitis has resolved, restart the same Ethionamide (Eto)
drugs except replace 'Z' with 'S' to complete the Protionamide (Pto)
2 months course of initial therapy, followed by Groups Clofazimine (Cfz)
R&H for 6 month continuation phase Agents with unclear Linezolid (Lzd)
role in treatment of Amoxicillin / Clavulanate (Amx/CI)
7. When hepatitis with Jaundice occurs during the drug-resistantTB Thioacetazone (Tlz)
continuation phase: Once hepatitis has resolved, lmipenem /Cilastatin (lpm/Cln)
restart 'H' & 'R" to complete the 4 - month High - dose lsoniozid (high-dose H)
continuation phase of treatment. Clarithromycin (Cir)

Treatment of MDR-TB Karamycin + Levofloxacin / Otloxacin + Cycloserine


+ Ethionamide
Once MDR-TB is confirmed, patients can be treated
with: Continuation Phase : Ethambutol + Levotloxacin /
a. Standard MDR regimen (Standardized Otlaxcin + Cycloserine + Ethionamide.
approach); OR Duration of treatment for MDR TB
b. An individually tailored regimen, based on DST 1. Intensive phase · defined by the treatment
of additional drugs duration with injectable agent. It should be
General principles of designing MDR regimen continued for a minimum of 6 months, and for
1. Use at least 4 drugs certain to be effective (Each atleast 4 months after the patient first becomes
drug from different class). and remains smear or culture negative.
2. Do not use drugs for which there is possibility 2. Continuation phase - Minimum of 18 months
of cross resistance. after culture conversion. Extension of therapy
to 24 months may be indicated in chronic cases
3. Eliminate drugs that are not safe.
with extensive pulmonary damage.
4. Include drugs from Groups 1-5 in a hierarchical
Monitoring MDR - TB patient
order based on potency. [For regimens
containing fewer than 4 drugs, consider adding 1. Sputum smears and culture should be performed
group 5 drugs. Regimen often contains 5- 7 monthly until smear and culture conversion
drugs). [conversion is defined as two consecutive
Regimen used in India : negative smears and cultures taken 30 days
apart).
Intensive phase - Pyranzinamide + Ethambutol +

167
PRACTICAL MEDICINE

2. After conversion, bacteriological monitoring is treatment and develop new drugs that
recommended monthly for smears and quarterly target these specific genes.
for cultures. Factors influencing response to treatment
3. Monitoring by clinician should be at least 1. Adequate Chemotherapy
monthly until sputum conversion, then every 2. Regular Intake of Drugs (Compliance)
2-3 months.
3. Optimal Duration
4. Weight should be monitored monthly.
4. Severity Of Disease
5. Such large number of smear and culture for 5. Rest
follow up is not possible at least 5 smears and
6. Diet
cultures must be done at follow up (4, 6, 12, 18
and 24 months). 7. Nursing
6. X-ray should be done every 6 months. 8. Climate
Adjuvant Therapies for MDR - TB 9. Psychological Factors
III. Corticosteroids: Corticosteroids are useful
l. Surgery: Resection Surgery -indicated in patients
in tuberculosis because· they exert anti­
who remain sputum positive, with resistance to
inflammatory, anti-allergic and anti-collagenous
large numberof drugs, and localised pulmonary
effects. Indications:
disease. Chemotherapy to be given 2 months
prior and continued 18-24 months post surgery. I. Tuberculous meningitis
2. Collapse therapy : Reversible surgical therapy 2. Miliary tuberculosis
which involves collapse of lung by artificial 3. Tuberculosis of adrenal glands with
pneumoperitoneum or pneumothorax used Addison's disease
for cavity containing diseased lung. 4. Tuberculosis ofserous sacs, ureter, fallopian
3. Laser therapy tubes.
a. Tried in some countries. 5. Drug hypersensitivity
b. Effective in multicavitatory disease with Corticosteroids are given in the dose of 40-60
heavy bacterial load. mg/day of prednisolone for 6-8 weeks, and
tapered over the next 2-3 weeks. They are to be
c. Thought to have a role in rapid killing given only under the cover of anti-tuberculous
of bacteria; increases and improves therapy, otherwise there may be flaring up of
penetration of Anti TB drugs in walled tuberculosis.
off lesions and helps in early closure of
cavities. It is of proven benefit in tracheal

4.
and endobronchial growth.
Immunotherapy and Immunomodulation.
10 > Chronic Obstructive
a. Use of Mycobacterium Vaccine.
Pulmonary Disease
b. Enchancing pro-inflammatory cytokines (COPD) (Emphysema
• IL2, IL 12, IFN-y, TNF-a., Inhibiting and Chronic Bronchitis)
anti-inflammatory cytokines IL-4, 5, I 0.
c. Use of Thalidomide, Transfer factor, Definition
Indomethacin, Levamisole. Emphysema is characterized by enlargement of the
d. Mycobacteriumw (lmmuvac) - has been airspaces distal to the terminal bronchioles, either
used in Leprosy. from dilatation or destruction of their walls.
5. Gene Therapy Chronic bronchi tis is dinically defined aschronic cough
with expectoration for three months for two consecu­
To detect drug resistance before start of
tive years, with other known causes being ruled out.

168
{ 4 ) Respiratory System
COPD is a common preventable and treatable disease, cigar, water pipe) and maijuana are
characterized by progressive airflow limitation associ­ also risk factor.
ated with an enhanced chronic inflammatory response c. Passive exposure to smoke - also
to noxious particles or gases. known as environmental tobacco
Exacerbations and comorbidities contribute to overall smoke.
severity on individual patients. d. Smoking during pregnancy affects
Mechanisms of Airflow Limitation in COPD: fetus by affecting lung growth and
Srnal I Airway disc,um l'arunchymal <lcslrucl ion development of immune system.
Airway innunmmlion Loss of alveolar auachmonts
Ainvay fibrosis. Lmnitml plugs Dt.."Crc.:1scd Elastic Recoil
e. Occupational exposures, including
I
Incrcasccl airway resistance organic and inorganic dust and
� Airflow Limilution __J chemical agents and fumes are
appreciated risk factors.
Prevalence f. Wood, Animal during, crop residues
and coal, typically burned in open
I. Higher in smokers than non smokers
fires or poorly functioning stoves or
2. Higher in those over age 40 heating in poorly ventilated dwelling
3. Higher in men than women. - important risk factor.
Risk factors influencing disease g. Outdoor air pollution - in urban areas.
development and prognosis Role is unclear, but is small compared
to smoking. Air pollution from fossil
A. Genetic predisposition : fuel combustion is associated with
l. a-1 Antitrypsin gene decrement in lung function.
2. MMP 12 gene 5. Socio economic status: Poverty is clearly a
3. a-nicotine ACh receptor risk factor but the components of poverty
that contribute to this are unclear. Risk is
4. Hedge Hog interactivity protein gene
inversely related to socioeconomic state.
B. Environmental factors 6. Asthma I Bronchial hyper reactivity :
1. Age: Ageing itselfis a risk factor for COPD. a. Asthma may be a risk factor but
2. Gender: In past prevalence was more in evidence is not conclusive.
men than women. But due to increase in b. Bronchial hyp er reactivity can
smoking in women prevalence rates are exist without clinical diagnosis of
now approaching equality. asthma and has been shown to be an
3. Lung growth and development important predictor of COPD as well
a. Any factor that affects lung growth as an indicator of increased risk of
during Gestation and childhood has decline in lung function in patients
potential for increasing individual with mild COPD.
risk for COPD. 7. Infection
b. Factorsin early life termed "Childhood a. Severe childhood respiratory infection
Disadvantage Factors" were as has been associated with reduced lung
important as heavy smoking is in function and increased respiratory
predicting in early adult life. symptoms in adulthood.
4. Exposure to Particles b. Susceptibility to infection plays an
a. Cigarette smoke important role in exacerbation of
COPD but effect on development of
b. Other types of tobacco (e.g. pipe, disease in less clear.

169
PRACTICAL MEDICINE

c. HIV - accelerate onset of smoking Investigations


related emphysema.
A. Spirometry : Presence of post bronchodilator
d. TB is a risk factor for COPD. FEY 1 / FVC < 0.7 confirms the presence of
Causes persistent airflow limitation and thus ofCOPD.
It is also used to grade the severity of COPD
I. Localized (given below).
A. Congenital B. Arterial Blood Gas : Retetion o f C0 1 in
B. Compensatory due to lung collapse, Emphysema.
scarring or resection C. X-ray chest
C. Partial bronchial obstruction 1. Hyper translucency of lung fields
l. Neoplasm
2. Widened intercostal spaces
2. Foreign body
3. Low flat diaphragm
D. MacLeod'syndrome
4. Increased retrosternal translucency
II. Generalized
5. Narrow vertical heart • Tubular heart
A. Idiopathic
6. Large hilar shadows
B. Senile
7. Diminished peripheral vascular pattern
C. Familial (alpha-I-anti-trypsin deficiency)
8. Bullae: Roundedareasofhypertranslucency
D. Associated with chronic bronchitis.asthma with thin hairline shadow forming the
or pneumoconiosis. margin
Diagnosis D. HRCT Chest is currently the definitive test to
diagnose emphysema.
A. General condition: Patient may be emaciated,
cyanosed and edematous (blue bloater). JVP E. Serum a 1 AT Level to diagnose a 1 AT deficiency.
may show giant a-waves. Table 4.21 : Differences between Pink­
B. Chest finding s: Refer Pg. 134 puffer and Blue-bloater
Pink-puffer Blue-bloater
C. Heart
1. Course Progressive dyspnea Intermittent
1. Apex beat may not be visible or palpable.
dyspnea
2. Right ventricular heave may be present.
2. Sputum Scanty Profuse
3. Heart sounds may be diminished. Second
3. Polycythemia Uncommon Common
sound may be loud. Gallop rhythm may
be present. In marked emphysema, RV 4. X-ray Attenuated periph- Normal
eral vessels peripheral
heave may not be visible or felt because vessels
the hyperinflated lung may cover it. In
5. p(02 Normal Normal
such cases, epigastric pulsations may be
the only evidence of RV enlargement 6. Alveolar gas Reduced Normal
transfer
4. Functional tricuspid regurgitation murmur
may be present. Assessment of Disease
5. Hyperkinetic state with warm limbs and
The degree of airflow limitation is an important
Waterhammer pulse may be present.
prognostic factor. Global Initiative for Luung Disease
D. Miscellaneous (GOLD)criteriagradesseverityofCOPDbasedonSpi­
l. Liver may be enlarged. rometry. However a multifactorial index incorporating
2. Optic disc may show papilledema. symptoms spirometry, exacerbations and excercise

170
{ 4 > Respiratory System

performance has shown to be a better predictor of 2. Ampicillin 0.5 gm 6 hourly.


prognosis than only spirometry. 3. Chloramphenicol 0.5 gm 6 hourly.
Treatment If there is Pseudomonas infection the
Of acute Exacerbation following drugs may be used:
J.
An acute event is characterised by worsening of 1. Gentamicin 80 mg 8 hourly l.M. or
patients respiratory symptoms that is beyond 2. Ciprofloxacin 0.5 gm 6 hourly orally
normal day to day variantions or leads to a or 200 mg IV 12 hourly.
change in medication. Frequent exacerbations 3. Ceftazidime l gm IV 6 hourly.
are those occuring > twice a year.
B. Oxygen Therapy : This is required to attain
It is precipitated by inection, allergic reactions, adequate oxygenation. However, in some
other systemic illness or air pollution. patients with chronic obstructive airway
A. Chemotherapy: Antibiotics are required as disease and hypercapnia, the respiratory
infection often precipitates acute attacks. centre would have lost its normal sensitivity
One of the following drugs may be used: to carbon dioxide and would become
IfH. influenza, streptococci, staphylococci dependent on the hypoxic drive to
or Klebsiella is the cause: maintain respiration. In such cases oxygen
1. Benzyl penicillin 10lakh units6 hourly must be given with care and preferably
with streptomycin 0.5 gm 12 hourly. intermittently (Refer Chapters 7 and 11).
C. Bronchodilators: Aminophylline 0.25·
0.5 gm. LV. slowly not only relaxes the
bronchial muscles but also stimulates the
respiratory centre and assists in clearing the
respiratory tract. Salbutamol inhalations
are also useful as they are selective beta
stimulants.
D. Corticosteroids: The role of corticosteroids
in acute exacerbations is uncertain.
E. For cor pulmonale: If the patient is in cor
pulmonale, diuretics like furosemide,
digitalis and potassium saltsmust be given.
F. Avoiding bronchial irritants: Smoking must
be avoided. Atmospheric pollution too
Fig 4.40 Emphysema must be avoided, but it may not be practical.

Table 4.22: Gold Criteria


Gold Stage Severity Symptoms Spirometry
0 At Risk Chronic Cough, Sputum Production Normal
Mild With or without chronic cough or sputum FEV,I FVC < 0.7 and FEV, � 80% predicted
production
2 Moderate With or without chronic cough or sputum FEV ,I FVC < 0.7 and FEV, 50-80% predicted
production
3 Severe With or without chronic cough or sputum FEV,f FVC < 0.7 and FEV, 30-50% predicted
production
4 Very Severe With or without chronic cough or sputum FEV, / FVC < 0.7 and FEV, :5 30% predicted OR
production FEV 1 < 50% predicted with respiratory failure or
signs of right heart failure

171
PRACTICAL MEDICINE

However patient must stay indoors in foggy has concurrent OSA then there is a definite
weather and sleep with dosed windows. benefit.
G. Expectorants and mucolytic agents: A hot VII. LVRS (Lung Volume Reduction Surgery) is a
drink acts as a simple expectorant in surgical procedure in which parts of lungs
clearing the airways. Bromhexine has been are resected to reduce hyperinflation, making
found useful in liquefying sputum and respiratory muscles more effective by improving
aiding airway clearance. their mechanical efficiency (lengh / tension
H. Chest physiotherapy: Postural drainage relationship).
and proper breathing exercises, especially Increase elastic recoil pressure � improves
expiration, must be taught to the patient. expiratory flow rates and reduces exacerbation.
II. Long term management: It is more beneficial in predominant upper lobe
I. Quit smoking emphysema.
II. A. Bronchodilators VIII. Broncltoscopic LVR shows modest improvement:
Increase chances of pneumonia, hemoptysis,
1. � 2 agonists • Shortacting - Fenoterol,
COPD exacerbation
Salbutamol, levosalbutamol. Longacting :
Formoterol. Indacaterol, Salmeterol. IX. Lung Transplant
2. Anticholingergics - short acting Criteria-: any l
Ipratropium bromide oxitropium bromide. a. History of exacerbation - associated
Long acting : Tiotropium. with hypercapnia.
3. Methylxanthines (minimal role now) b. Pulmonary Hypertension or Cor
Aminophylline, Theophylline pulmonale, despite 02 Treatment.
B. Steroids c. FEV 1 < 20% predicted with DLCO <
20% with homogenous distribution
of emphysema.
Inhaled Systemic X. Bullectomy: in Bullous emphysema.
- Beclomethasone • Prednisolone
- Budesomide - Methylpruclnisole
- Fluticasone
11 Pneumonia
C. PDE - 4 inhibitors - Roflumilast
Definition: Pneumonia is inflammation of the pa­
III. Pulmonary rehabilitation - exercise training renchyma of the lung.
IV. Vaccines - H influenza and pneumococcal
vaccine yearly. Etiology
V. Home 02 : > I 5 hr/ day, in patients with chronic l. Bacterial: Pneumococcus, Staphylococcus,
respiratory failure has shown to increase survival. Streptococcus, H. influenza, E. coli, Klebsiella,
Pseudomonas, etc.
Indication
2. Atypical: Viral, Rickettsial, Mycoplasmal.
L Pa0 2 < 55 mmHg or Sa02 < 88%.
3. Protozoa!: E. histolytica.
2. Pa0 2 <60 or Sa0 2 < 88% with evidence
of pulmonary HT, Peripheral edema
4. Fungal: Actinomycosis, As pergillosis,
Histoplasmosis, Nocardiosis.
suggestive ofcongestive cardiac failure and
polycythemia 5. Allergic: Loeffler's syndrome.
VI. Non-Invasive Ventillation (BiPAP): is useful in 6. Radiation
those with pronounced daytime hypercapnia. 7. Collagenosis: SLE, Rheumatoid arthritis,
Improves survival but not quality oflife. If patient Polyarteritis nodosa.

172
( 4 > Respiratory System

8. Chemical: 2. Elderlywith chronic lung disease: Pneumococci,


a. Aspiration of vomitus or due to dysphagia H. influenza, Legionella, Mycoplasma and
as in hiatus hernia and achalasia cardia. Chlainydia
b. Toxic: Gases and smokes. 3. Hospitalized patients: Pseudomonas, Proteus,
c. Lipoid: Kerosene, paraffin and petroleum. Klebsiella, E. coli, Staphylococcus aureus,
anaerobic organisms
Predisposing Factors (Alter Host
Defense) Site of Pneumonia
1. Right lung is commonly involved because it is in
1. Exposure to cold facilitates the passage of
continuity with the trachea
mucus containing pneumococci from the upper
respiratory tract to the lower. 2. Recumbent patient: Posterior segment of upper
lobe and superior segment of lower lobe are
2. Postoperative especially after abdominal
involved.
operations, because anesthetic agents suppress
respiratory defenses, diaphragmatic movements 3. In sitting up position: Basal segments of lower
are decreased and cough is limited due to pain lobe are involved.
and sedation. 4. Apical: Tuberculosis or Klebsiella
3. Smoking. chronic bronchitis, alcohol. Clinical Features
4. Infection of the upper respiratory tract, sinuses A. Pneumococcal
and bronchi. 1. History of common cold or upper
5. Debilitating illnesses and poor nutrition respiratory tract infection
6. Immunological deficiencies 2. Fever wi