Rabies

Introduction to the disease

Rabies is a deadly viral disease that affects the central nervous system of mammals, including
humans. It is transmitted through the bite or scratch of an infected animal, usually a dog or a
wild animal. Rabies causes severe symptoms such as fever, headache, confusion, hallucinations,
paralysis, and hydrophobia (fear of water). Rabies is almost always fatal once symptoms appear,
but it can be prevented by vaccinating animals and people, and by seeking immediate medical
care after exposure.

Etiologic agent - describe the microbe

The etiologic agent of rabies is the rabies virus, which belongs to the genus Lyssavirus, family
Rhabdoviridae. The rabies virus is a bullet-shaped, enveloped, single-stranded RNA virus that
has a negative-sense genome. The virus has five structural proteins: nucleoprotein (N),
phosphoprotein (P), matrix protein (M), glycoprotein (G), and polymerase (L). The G protein is
responsible for binding to receptors on host cells and mediating viral entry, while the N, P, and
L proteins form the ribonucleoprotein complex that replicates and transcribes the viral genome.
The M protein links the envelope and the ribonucleoprotein complex and plays a role in virus
assembly and budding.

Mode of transmission
The mode of transmission of rabies is through direct contact with the saliva or nervous tissue of
an infected animal. The most common route of transmission is through the bite of a rabid
animal, which introduces the virus into the wound. The virus then travels along the peripheral
nerves to the central nervous system, where it replicates and causes inflammation and damage to
the brain and spinal cord. The virus can also spread to other organs, such as the salivary glands,
where it can be secreted into the saliva. Other routes of transmission include scratches, licks, or
contact with mucous membranes or open wounds. Rarely, rabies can be transmitted through
organ or tissue transplantation, aerosol exposure, or laboratory accidents.

Clinical manifestations - signs and symptoms

The clinical manifestations of rabies depend on the stage of the disease and the type of rabies.
The incubation period of rabies varies from a few days to several years, depending on the
location and severity of the wound, the amount and strain of the virus, and the immune status of
the host. The average incubation period is 1 to 3 months. The disease can be divided into three
stages: prodromal, neurologic, and coma.

 Prodromal stage: This stage lasts for 2 to 10 days and is characterized by flu-like
symptoms, such as fever, headache, malaise, anorexia, nausea, vomiting, and sore throat.
The wound may become painful, itchy, or numb. The patient may also experience
anxiety, depression, agitation, insomnia, or abnormal behavior. Some patients may have
paresthesia (tingling or burning sensation) or hyperesthesia (increased sensitivity) around
the wound or in the affected limb.
  Neurologic stage: This stage lasts for 2 to 7 days and is marked by the onset of
neurological symptoms, such as confusion, disorientation, hallucinations, delirium,
paranoia, aggression, seizures, muscle spasms, difficulty swallowing, drooling, and
hydrophobia. There are two types of neurologic rabies: furious and paralytic. Furious
rabies accounts for about 80% of human cases and is characterized by hyperactivity,
excitability, and rage. Paralytic rabies accounts for about 20% of human cases and is
characterized by progressive paralysis, starting from the wound site and spreading to the
rest of the body.
 Coma stage: This stage is the final stage of the disease and leads to death within a few
days. The patient becomes unresponsive, comatose, and hypotensive. The patient may
develop respiratory failure, cardiac arrest, or multiple organ failure. Death is usually due
to respiratory or cardiac arrest.

How the disease is diagnosed/Diagnostic test

The diagnosis of rabies is challenging because the symptoms are nonspecific and the virus is
difficult to detect in the early stages of the disease. The diagnosis is usually based on the history
of exposure, the clinical signs, and the laboratory tests. The laboratory tests include:

 Fluorescent antibody test (FAT): This is the most widely used and reliable test for rabies.
It involves staining a sample of brain tissue or saliva from the suspected animal or patient
with fluorescent antibodies that bind to the rabies virus. The sample is then examined
under a microscope for the presence of fluorescent viral antigens. The FAT can provide a
rapid and definitive diagnosis of rabies, but it requires specialized equipment and trained
personnel.
 Reverse transcriptase polymerase chain reaction (RT-PCR): This is a molecular test that
amplifies and detects the viral RNA from a sample of brain tissue, saliva, skin, or
cerebrospinal fluid. The RT-PCR can provide a sensitive and specific diagnosis of rabies,
but it requires sophisticated equipment and expertise.
 Virus isolation: This is a method that involves inoculating a sample of brain tissue or
saliva into cell culture or animals and observing for signs of infection. The virus isolation
can confirm the diagnosis of rabies, but it is time-consuming, expensive, and hazardous.
 Serology: This is a method that measures the level of antibodies against the rabies virus in
the blood or cerebrospinal fluid of the patient. The serology can indicate a previous or
current exposure to the virus, but it is not useful for the diagnosis of acute rabies, as the
antibody response may be delayed or absent.

Treatment
There is no specific treatment for rabies once symptoms appear. The treatment is mainly
supportive and palliative, aiming to relieve the pain and suffering of the patient and to prevent
complications. The treatment may include:

 Wound care: The wound should be cleaned and disinfected as soon as possible after
exposure to reduce the risk of infection and viral entry. The wound may be sutured if
necessary, but only after thorough irrigation and debridement.
 Post-exposure prophylaxis (PEP): PEP is the administration of rabies vaccine and rabies
immunoglobulin (RIG) to a person who has been exposed to a potentially rabid animal.
 PEP can prevent the development of rabies if given before the onset of symptoms. PEP
consists of:
o Rabies vaccine: The rabies vaccine is an inactivated or recombinant vaccine that
stimulates the immune system to produce antibodies against the rabies virus. The
vaccine is given intramuscularly in a series of four or five doses, depending on the
type of vaccine and the risk of exposure. The first dose should be given as soon as
possible after exposure, preferably within 24 hours, and the subsequent doses
should be given on days 3, 7, 14, and 28.
o Rabies immunoglobulin (RIG): RIG is a preparation of human or equine antibodies
that neutralize the rabies virus. RIG is given intramuscularly or infiltrated into the
wound as a single dose, preferably within 6 hours of exposure, and no later than 7
days after the first dose of vaccine. RIG provides immediate passive immunity
until the vaccine induces active immunity.
 Symptomatic and supportive care: The patient should be hospitalized and isolated in a
quiet and dark room to reduce sensory stimulation and agitation. The patient should
receive adequate hydration, nutrition, and oxygenation. The patient should also receive
medications to control pain, fever, seizures, spasms, anxiety, and agitation. Sedatives,
anticonvulsants, muscle relaxants, and opioids may be used, but care should be taken to
avoid respiratory depression. The patient should be monitored for signs of respiratory or
cardiac failure and treated accordingly.

Prevention/Vaccination
The prevention of rabies is based on the following strategies:

 Vaccination of animals: The vaccination of domestic and wild animals is the most
effective way to prevent rabies in animals and humans. The vaccination of dogs, cats, and
other pets should be done regularly and according to the national or local guidelines. The
vaccination of livestock, such as cattle, sheep, and goats, may also be beneficial in some
areas. The vaccination of wildlife, such as raccoons, skunks, foxes, and bats, may be done
through oral baits or traps.
 Control of stray and feral animals: The control of stray and feral animals, especially dogs,
is important to reduce the risk of rabies transmission and exposure. The control measures
may include registration, identification, sterilization, adoption, and euthanasia of
unwanted animals. The control of animal population should be done in a humane and
ethical manner, respecting animal welfare and public health.
 Education and awareness: The education and awareness of the public, especially children,
is essential to prevent rabies and to promote responsible pet ownership and animal
welfare. The education and awareness programs should include information on the signs
and symptoms of rabies, the mode of transmission, the risk of exposure, the importance of
vaccination, the prevention of dog bites, and the management of animal bites.
 Surveillance and reporting: The surveillance and reporting of rabies cases in animals and
humans is vital to monitor the epidemiology and the impact of rabies, and to guide the
prevention and control interventions. The surveillance and reporting system should
involve the collaboration of the veterinary, public health, and laboratory sectors, and the
use of standardized case definitions, diagnostic methods, and data collection tools.
 Post-exposure prophylaxis: PEP is the administration of rabies vaccine and RIG to a
person who has been exposed to a
Pneumonia
Introduction to the disease
Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up
of small sacs called alveoli, which fill with air when a healthy person breathes. When an
individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing
painful and limits oxygen intake. Pneumonia can cause mild to life-threatening illness in people
of all ages, but it is the single largest infectious cause of death in children worldwide.
Pneumonia killed more than 808 000 children under the age of 5 in 2017, accounting for 15% of
all deaths of children under 5 years. People at-risk for pneumonia also include adults over the
age of 65 and people with preexisting health problems.

Etiologic agent - describe the microbe

Pneumonia can be caused by a variety of organisms, including bacteria, viruses, and fungi. The
most common causes of pneumonia vary depending on the age, geographic location, and health
status of the patient. Some of the common etiologic agents of pneumonia are:

 Bacteria: The most common cause of bacterial pneumonia in adults is Streptococcus

pneumoniae, also known as pneumococcus. Other bacteria that can cause pneumonia
include Haemophilus influenzae, Staphylococcus aureus, Mycoplasma pneumoniae,
Legionella pneumophila, and Klebsiella pneumoniae. Bacteria can cause pneumonia by
invading the lung tissue or by producing toxins that damage the alveoli. Bacterial
pneumonia is usually treated with antibiotics.
 Viruses: The most common cause of viral pneumonia in children and adults is the
respiratory syncytial virus (RSV), which is also a common cause of bronchiolitis in
infants. Other viruses that can cause pneumonia include influenza, parainfluenza,
adenovirus, coronavirus, rhinovirus, and human metapneumovirus. Viruses can cause
pneumonia by infecting the cells that line the respiratory tract or by triggering an
inflammatory response that damages the alveoli. Viral pneumonia is usually treated with
antiviral drugs or supportive care.
 Fungi: Fungal pneumonia is less common than bacterial or viral pneumonia, but it can be
more severe and difficult to treat. Fungal pneumonia is usually caused by inhaling spores
of fungi that are present in the soil or the environment, such as Histoplasma capsulatum,
Coccidioides immitis, Cryptococcus neoformans, Pneumocystis jirovecii, and Aspergillus
fumigatus. Fungal pneumonia can affect people with normal or weakened immune
systems, but it is more common and serious in people with HIV/AIDS, cancer, or organ
transplants. Fungal pneumonia is usually treated with antifungal drugs.

Mode of transmission
Pneumonia can be transmitted through direct or indirect contact with the causative agents. The
mode of transmission depends on the type and source of the infection. Some of the common
modes of transmission are:

 Inhalation: This is the most common mode of transmission of pneumonia. It occurs when
a person breathes in droplets or aerosols that contain the infectious agents. These droplets
 or aerosols can be generated by coughing, sneezing, talking, or breathing of an infected
person or animal. They can also be present in the air due to environmental factors, such as
dust, smoke, or pollution.
 Aspiration: This is a mode of transmission that occurs when a person inhales food,
liquids, saliva, or vomit that contain the infectious agents. This can happen when a person
has difficulty swallowing, has a reduced level of consciousness, or has a medical
condition that affects the gag reflex or the cough reflex. Aspiration can also occur during
intubation, ventilation, or anesthesia.
 Hematogenous: This is a mode of transmission that occurs when the infectious agents
enter the bloodstream from another site of infection or injury, such as the skin, the urinary
tract, or the heart. The infectious agents can then travel through the blood vessels and
reach the lungs, where they can cause pneumonia.
 Direct spread: This is a mode of transmission that occurs when the infectious agents
spread from an adjacent organ or tissue to the lungs, such as the pleura, the mediastinum,
or the chest wall. This can happen due to trauma, surgery, or a complication of another
disease, such as tuberculosis, lung abscess, or lung cancer.

Clinical manifestations - signs and symptoms

The signs and symptoms of pneumonia vary from mild to severe, depending on the type and
severity of the infection, the age and health status of the patient, and the response of the immune
system. Some of the common signs and symptoms of pneumonia are:

 Cough: This is a symptom that occurs when the airways are irritated or inflamed by the
infection. The cough can be dry or productive, meaning that it can bring up mucus or
phlegm. The mucus or phlegm can be clear, white, yellow, green, or bloody, depending
on the cause and stage of the infection. The cough can be worse at night or in the
morning, and it can be triggered by cold air, exercise, or lying down.
 Fever: This is a symptom that occurs when the body temperature rises above the normal
range, usually 98.6 F (37 C). Fever is a sign of inflammation and infection, and it can be
accompanied by chills, sweating, and shivering. Fever can range from mild to high,
depending on the severity of the infection and the response of the immune system. Fever
can also cause headache, muscle ache, and fatigue.
 Dyspnea: This is a symptom that occurs when a person has difficulty breathing or feels
short of breath. Dyspnea can be caused by the reduced oxygen intake due to the infection,
the increased work of breathing due to the inflammation, or the accumulation of fluid or
pus in the alveoli. Dyspnea can be worse with exertion, lying down, or coughing, and it
can cause anxiety, restlessness, and cyanosis (bluish discoloration of the skin or lips).
 Chest pain: This is a symptom that occurs when a person feels pain or discomfort in the
chest, usually on the side of the infection. Chest pain can be caused by the inflammation
of the lung tissue, the pleura, or the chest wall, or by the coughing or breathing
movements. Chest pain can be sharp, stabbing, or dull, and it can be worse with
breathing, coughing, or movement.
 Other symptoms: Depending on the cause and extent of the infection, pneumonia can also
cause other symptoms, such as:
o Nausea, vomiting, or diarrhea
o Loss of appetite or weight loss
o Confusion or delirium, especially in older adults or people with low oxygen levels
 o Wheezing or crackles, which are abnormal sounds heard with a stethoscope over
the lungs
o Tachycardia or tachypnea, which are increased heart rate or breathing rate

How the disease is diagnosed/Diagnostic test

The diagnosis of pneumonia is based on the history of exposure, the physical examination, and
the laboratory tests. The diagnosis can be confirmed by the following tests:

 Chest X-ray: This is a test that uses radiation to produce an image of the chest and the
lungs. A chest X-ray can show the presence, location, and extent of the infection, as well
as the presence of complications, such as pleural effusion, lung abscess, or pneumothorax.
A chest X-ray can also help to differentiate pneumonia from other conditions, such as
bronchitis, asthma, or heart failure.
 Blood tests: These are tests that measure the levels of different substances in the blood,
such as blood cells, electrolytes, and enzymes. Blood tests can help to assess the severity
of the infection, the response of the immune system, and the presence of other diseases or
conditions. Some of the common blood tests for pneumonia are:
o Complete blood count (CBC): This is a test that measures the number and type of
blood cells, such as red blood cells, white blood cells, and platelets. A CBC can
show signs of infection, such as increased white blood cells, or signs of anemia,
such as decreased red blood cells.
o Blood culture: This is a test that involves taking a sample of blood and growing it
in a laboratory to identify the causative agent of the infection. A blood culture can
confirm the diagnosis of pneumonia, especially if the infection is caused by
bacteria or fungi, and it can help to guide the choice of antibiotics.
o C-reactive protein (CRP): This is a test that measures the level of a protein that is
produced by the liver in response to inflammation. A CRP can indicate the
presence and severity of the infection, and it can help to monitor the response to
treatment.
o Procalcitonin (PCT): This is a test that measures the level of a protein that is
produced by the thyroid gland in response to bacterial infection. A PCT can help to
differentiate bacterial pneumonia from viral pneumonia, and it can help to guide
the use of antibiotics.
 Sputum tests: These are tests that involve taking a sample of mucus or phlegm that is
coughed up from the lungs and analyzing it in a laboratory. Sputum tests can help to
identify the causative agent of the infection, and they can help to determine the sensitivity
or resistance of the agent to antibiotics. Some of the common sputum tests for pneumonia
are:

Treatment
Treatment The treatment of pneumonia depends on the type and severity of the infection,
the age and health status of the patient, and the response to the medication. The main
goals of treatment are to cure the infection, relieve the symptoms, and prevent
complications. The common treatment options for pneumonia are:
Medication: The medication for pneumonia varies according to the causative agent of the
infection. The medication can be given orally or intravenously, depending on the condition of
the patient. The common types of medication for pneumonia are:
o Antibiotics: These are drugs that kill or inhibit the growth of bacteria. Antibiotics
are used to treat bacterial pneumonia, and sometimes fungal or mycoplasma
pneumonia. The choice of antibiotic depends on the type and sensitivity of the
bacteria, and the presence of any drug allergies or resistance. The common
antibiotics for pneumonia include penicillins, cephalosporins, macrolides,
fluoroquinolones, and tetracyclines. Antibiotics should be taken as prescribed and
for the full course of treatment, even if the symptoms improve, to prevent relapse
or resistance.
o Antivirals: These are drugs that interfere with the replication or function of viruses.
Antivirals are used to treat viral pneumonia, especially if caused by influenza or
RSV. The common antivirals for pneumonia include oseltamivir, zanamivir, and
ribavirin. Antivirals should be started as soon as possible after the onset of
symptoms, preferably within 48 hours, to reduce the severity and duration of the
infection.
 Antifungals: These are drugs that kill or inhibit the growth of fungi. Antifungals are used
to treat fungal pneumonia, especially if caused by Pneumocystis jirovecii, Histoplasma
capsulatum, or Aspergillus fumigatus. The common antifungals for pneumonia include
fluconazole, itraconazole, and amphotericin B. Antifungals should be taken as prescribed
and for the full course of treatment, even if the symptoms improve, to prevent relapse or
resistance.
 Symptomatic and supportive care: These are drugs that help to relieve the symptoms and
complications of pneumonia, such as fever, pain, cough, and breathing difficulty. The
common symptomatic and supportive drugs for pneumonia include:
o Analgesics: These are drugs that reduce pain and inflammation. The common
analgesics for pneumonia include acetaminophen, ibuprofen, and naproxen.
Analgesics should be taken as needed and with caution, as they may have side
effects such as stomach irritation, liver damage, or bleeding.
 Antipyretics: These are drugs that lower fever and reduce sweating and shivering. The
common antipyretics for pneumonia include acetaminophen, ibuprofen, and naproxen.
Antipyretics should be taken as needed and with caution, as they may have side effects
such as stomach irritation, liver damage, or bleeding.
 Cough suppressants: These are drugs that reduce the urge to cough and the production of
mucus. The common cough suppressants for pneumonia include dextromethorphan,
codeine, and guaifenesin. Cough suppressants should be used sparingly and with caution,
as they may have side effects such as drowsiness, nausea, or constipation. Cough
suppressants should not be used if the cough is productive, as it may interfere with the
clearance of the infection.
 Bronchodilators: These are drugs that relax the muscles of the airways and improve the
airflow to the lungs. The common bronchodilators for pneumonia include albuterol,
ipratropium, and salmeterol. Bronchodilators should be used as prescribed and with
caution, as they may have side effects such as palpitations, tremors, or nervousness.
Bronchodilators are usually given by inhalation, using a device such as a metered-dose
inhaler, a nebulizer, or a spacer.
 Oxygen therapy: This is a treatment that provides supplemental oxygen to the patient,
either through a nasal cannula, a face mask, or a ventilator. Oxygen therapy is used to
treat hypoxemia, which is a condition where the oxygen level in the blood is lower than
 normal. Oxygen therapy can improve the oxygen delivery to the tissues and organs, and
reduce the work of breathing and the strain on the heart. Oxygen therapy should be
monitored and adjusted according to the patient’s condition and oxygen saturation.

Therapy: The therapy for pneumonia involves non-pharmacological interventions that aim to
improve the patient’s condition and prevent complications. The common therapies for
pneumonia include:
 Hydration: This is a therapy that involves drinking plenty of fluids, such as water, juice,
or broth, to prevent dehydration and to thin the mucus in the lungs. Hydration can help to
ease the cough and to flush out the toxins from the body. Hydration should be done as
tolerated and with caution, as too much fluid intake may cause fluid overload or
electrolyte imbalance.
 Nutrition: This is a therapy that involves eating a balanced and healthy diet, rich in
protein, vitamins, minerals, and antioxidants, to boost the immune system and to promote
healing. Nutrition can help to prevent malnutrition and weight loss, and to provide energy
and strength to the body. Nutrition should be done as tolerated and with caution, as some
foods may cause allergies, intolerance, or interactions with the medication.
 Rest: This is a therapy that involves getting enough sleep and avoiding physical exertion,
to conserve energy and to allow the body to recover. Rest can help to reduce the stress
and inflammation, and to enhance the immune response and healing. Rest should be done
as needed and with caution, as too much rest may cause muscle weakness or blood clots.

Physiotherapy: This is a therapy that involves performing exercises and techniques that help
to clear the airways and improve the lung function. Physiotherapy can help to prevent
atelectasis, which is a condition where the alveoli collapse and cause breathing difficulty.
Physiotherapy can also help to prevent pneumonia in patients who are bedridden or have
reduced mobility. Physiotherapy should be done as prescribed and with caution, as some
exercises or techniques may cause pain, discomfort, or injury. Physiotherapy may include:
 Breathing exercises: These are exercises that involve inhaling and exhaling deeply and
slowly, using the diaphragm and the abdominal muscles. Breathing exercises can help to
expand the lungs, increase the oxygen intake, and loosen the mucus in the airways.
 Coughing exercises: These are exercises that involve coughing forcefully and effectively,
using the abdominal muscles and a tissue or a mask. Coughing exercises can help to expel
the mucus and the infection from the lungs.
 Chest percussion and vibration: These are techniques that involve tapping or vibrating the
chest wall with the hands or a device, while the patient is lying down or sitting up. Chest
percussion and vibration can help to loosen the mucus and move it to the larger airways,
where it can be coughed out.
 Postural drainage: This is a technique that involves positioning the patient in different
angles, with the head lower than the chest, to allow gravity to drain the mucus from the
different parts of the lungs. Postural drainage can help to clear the airways and improve
the ventilation.
 Incentive spirometry: This is a device that involves inhaling through a mouthpiece and
raising a ball or a piston in a chamber, to measure the lung volume and capacity.
Incentive spirometry can help to encourage deep breathing, expand the lungs, and prevent
atelectasis.
Prevention/Vaccination
Prevention/Vaccination The prevention of pneumonia involves reducing the exposure and the
susceptibility to the infection, and enhancing the immunity and the resistance to the infection.
The common prevention strategies for pneumonia are:

 Vaccination: This is a prevention method that involves injecting a weakened or killed

form of the causative agent of the infection, or a part of it, to stimulate the immune
system to produce antibodies and memory cells that can fight off the infection in the
future. Vaccination can prevent or reduce the severity of pneumonia caused by certain
bacteria or viruses, such as pneumococcus, influenza, or RSV. Vaccination is
recommended for people who are at high risk of pneumonia, such as children, older
adults, or people with chronic diseases or weak immune systems. Vaccination should be
done as prescribed and with caution, as some vaccines may have side effects such as pain,
swelling, or fever at the injection site, or allergic reactions.
 Hygiene: This is a prevention method that involves maintaining a clean and healthy
environment, and practicing good personal hygiene, to prevent the transmission and the
spread of the infection. Hygiene can prevent or reduce the exposure to the infectious
agents that cause pneumonia, such as bacteria, viruses, or fungi. Hygiene may include:
o Washing the hands frequently and thoroughly with soap and water, or using an
alcohol-based hand sanitizer, especially before and after eating, touching the face,
coughing, sneezing, or using the toilet.
o Covering the mouth and nose with a tissue or a mask, or using the elbow or the
shoulder, when coughing or sneezing, and disposing of the tissue or the mask
properly, to prevent the release of the infectious droplets or aerosols into the air.
o Avoiding touching the eyes, nose, or mouth with unwashed hands, to prevent the
entry of the infectious agents into the body.
o Cleaning and disinfecting the surfaces and objects that are frequently touched or
shared, such as door