A Family Doctor's Tale - ANAL FISTULA

DOC I HAVE AN ANAL FISTULA

Anal Fistula is a chronic granulous track which communicate between the anorectal canal and the perianal skin.
There may be several external openings but only one internal opening


Anal Fistula usually result from :
1.breakdown of anorectal abscesses


2.follows surgery for anal fissure


3.Less common causes are:
lymphogranuloma
carcinoma of rectum
ulcerative colitis,
tuberculosis


Symptoms are:

1.pain especially on sitting down
2.purulent painless discharge(pus) near the anus
3.Recurrent perianal abscesses(pockets of pus around the anus)
4.pruritis ani(itch in anus)


Diagnosis is by:

1.thorough examination of the perianal region
2.Rectal examination and palpation of the fistula track
3.Pass a probe through the perianal opening to determine the length of the track
4.Sigmoidoscopy and colonoscopy to detect internal opening and other lesions in the rectum and large intestine
5.Barium enema to exclude any ulcerative colitis and regional ileitis



There are 2 types of anal fistula:
1.High level fistulas penetrate the levator ani-muscle of the anal sphlinter
2.Low level fistulas are below the levator ani and are more common.


Treatment of lowlevel fistula:
lay open the track and curette(scrape the lining and debris in the track out


Treatment of high level fistula:
open the track from within the ischiorectal fossa
colostomy may be necessary for multiple fistulas or very high internal opening


General treatment:
1.Treatment of associated diseases like diabetes, ulcerative colitis,regional iliatis, carcinoma


2.Antibiotics - a full course of at least 2 weeks of antibiotics is needed


3.toilet and dressing of the wounds, with application of antibiotic creams


4.tub baths of the anal region several times a day in plain, warm water for about 10 minutes


Prognosis is good with surgery.
Rarely there may undesirable complication like rectal incontinence.

A Family Doctor's Tale - HEMORRHOIDS

DOC I HAVE PILES

Hemorrhoids or piles are a very common hidden disease that most patients are ashamed sometimes to tell their doctors. Often they may ask "By the way Doc I have this swelling at my anal area or bleeding when I pass motion".  Some of them will not even allow you to examine their anus to confirm the piles. A simple examination of the anal region can confirm hemorrhoids easily.

Hemorrhoids or piles are distended veins inside the anus which are swollen and inflamed. Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external).


Hemorrhoids usually result from straining to pass the stool out of anus. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea.


The most common symptom of internal hemorrhoids is bleeding from the anus.Bright red blood may be seen covering the stool, on toilet paper, or dripping from the anus into the toilet bowl.
There may be pain too especially if the stool is hard. This could be due to the hard stools pressing on the swollen piles or due to a tear in the inner lining of the anus.


A painful swelling or a hard lump around the anus may occur when a blood clot forms. This condition is known as a thrombosed hemorrhoid.


In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching.


Hemorrhoids are very common in both men and women. About half of the population have hemorrhoids by age 50.
Hemorrhoids are also common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. For most women, however, hemorrhoids caused by pregnancy are temporary.


A thorough examination and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.


The doctor will examine the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.


Closer evaluation of the rectum for hemorrhoids requires an exam with a proctoscope, useful for more completely examining the entire rectum.


To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and the entire colon with colonoscopy.
Colonoscopy is a diagnostic procedure that also involve the use of lighted, flexible tube inserted through the rectum.


a.Medical treatment of hemorrhoids is aimed initially at relieving symptoms. Measures to reduce symptoms include:


1.tub baths several times a day in plain, warm water for about 10 minutes
2.application of a hemorrhoidal cream or suppository to the affected area.
3. medicines such as daflon to shrink the swollen blood vessel.


b. surgical treatment:A number of methods may be used to remove or reduce the size of internal hemorrhoids.
These techniques include
1.Rubber band ligation. A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.
2.Sclerotherapy. A chemical solution is injected around the blood vessel to shrink the hemorrhoid.
3.Laser coagulation. A special device is used to burn hemorrhoidal tissue.
4.Hemorrhoidectomy. Occasionally, extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy.
5.A new method is the Longo technique. It involve using a circular stapling device which removes a ring of tissue in the lower anus pulling the enlarged piles up within the anus. The staples also interrupt the blood supply to the piles


The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs.


Drink lots of water at least eight glasses a day.


Eating the right amount of fiber result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Good sources of fiber are fruits, vegetables, bran bread, and whole grains.


Avoid food which cause local irritation of anus (spicy food,alcohol) or bowel excitation (coffee,tea)


Exercise, including walking, swimming, help reduce constipation and straining by producing stools that are softer and easier to pass.
Avoid certain sports such as cycling and horse -riding because of the pressure exerted on the anal region.


Avoid sitting in hot places for too long.


Use the toilet at a fixed time eg. after drinking a big glass of water, when you wake up.

A Family Doctor's Tale - PARKINSON'S DISEASE

                                             A Simple Guide To Parkinson's Disease        Kenneth Kee (C) 2007                              

DOC I HAVE PARKINSON'S DISEASE

Parkinson's Disease is quite common especially in the elderly patients of a family practice.
You can see them come in slowly , speak with a slurred speech and see their trembling hands and legs. 
More often than not a relative will accompany them. 
Many of them think that their condition is due to old age. 
That is true but their condition will only become worse with time. However there are new therapies which can improve their symptoms.

 Parkinson's Disease is a disorder of old age characterized by slow movement , rest tremors , rigidity and poor coordination.


 Parkinson's Disease usually after the age of  50 years.
Incidence is about 0.2% of population.
It is one of the most common neurologic disorders of the elderly.
It affects both men and women.

The cause of Parkinson's disease is still unknown.
Less than 5% of Parkinson's Disease patients gets the disease through genetic reasons.

A mutation of a gene (LRRK2) called G20135 has been found to increase the risk of Parkinson's disease in some families.

People with the mutated gene gets the illness at a younger age than the normal which is 60 and above.

The prevailing theory is that environmental factors such as exposure to high levels of pesticides is the cause of the disease.


 Parkinson's Disease results when the nerve cells in the part of the brain that controls muscle movement are gradually destroyed.
 Nerve cells use a brain chemical called dopamine to help send signals back and forth. Damage in the area of the brain that controls muscle movement causes a decrease in dopamine production. Low dopamine affects the balance between nerve-signalling substances (transmitters). As a result, the nerve cells cannot properly send messages. This results in the loss of muscle function.


Early symptoms may be nonspecific  and may include numbness, painful and tender muscles, stiffness and weakness  of limbs, fatigue and unexplained weight loss.


 As the disease progresses, the classical features of Parkinson's Disease appear:


1. Bradykinesia(slowness of movement)


2. leadpipe rigidity


3. rest tremors


4. Postural instabilty


  Parkinson's Disease is diagnosed when there are at least 2 of the four classical features are present.
  To improve diagnostic accuracy, bradykinesia must be present.
 1. Bradykinesia usually presents with lack of voluntary and automatic movement such as
 monotonous speech,
 lack of facial expression,
 Slow movements
Difficulty initiating any voluntary movement
Difficulty beginning to walk
Difficulty getting up from a chair
shuffling of feet movement 
 One way to demonstrate this is to have the patient tap  his index finger on his thumb. The movement is slow and lack momentum.


 2. Rigidity of  Parkinson's Disease is leadpipe in nature.
This rigidity contribute to the
 mask like facial appearance,
 Muscle rigidity
 stiffness of posterior neck muscles,
 diminished arm swing,
  cogwheel rigidity of the wrists .
  Difficulty bending arms or legs


 3.Rest tremor is classical of  Parkinson's Disease.
 There is this resting or pill rolling tremors of the hand which is worsened by anxiety and fatigue and disappears when the hand is in use. Tremor is usually unilateral.


 4. Postural instability usually occurs late in the illness.
 It is seen in the
 Unstable, stooped, or slumped-over posture
 freezing gait,
 retropulsion,
 loss of balance and falls
 Turning in bed, rising from the chairand turning when walking is difficult because of poor body and limbs coordination. 


 Additional symptoms that may be associated with this disease:


Depression
Confusion
Dementia
Seborrhea (oily skin)
Loss of muscle function or feeling
Muscle atrophy
Memory loss
Drooling
Anxiety, stress, and tension


 Untreated Parkinson's Disease  progresses to total disability, often accompanied by general deterioration of all brain functions, and may lead to an early death.


Treated, the disorder impairs people in varying ways.
Most people respond to some extent to medications.
The side effects of medications may be severe.
Varying degrees of disability
Difficulty swallowing or eating
Difficulty performing daily activities
Injuries from falls
Side effects of medications
A variety of gastrointestinal symptoms, mainly constipation
Daily activities such as bathing,dressing, walking and even writing may be difficult.


 Parkinson's Disease is not curable and the purpose of treatment is to:
1. improve functions and
2. treat symptoms


Treatment of  Parkinson's Disease can be broadly classified into:
1. Non-drug therapy:
    
     Good general nutrition and health are important.
     Exercises that improve strength, agility and flexibilty are useful to minimise the disability of  Parkinson's Disease. A range of motion exercises is useful to keep the joints supple and mobile. Patients are encouraged to exercise according to their ability. Good exercises include walking,swimming, stretching and riding stationary bicycles.
     Patients are taught sitting balance,walking techniques and the use of handrails. Activities of daily living is made more manageable
 with aids like:
 Buttoning     -replace buttons with velcros
 Eating           -use utensils with large handles
 Getting out of bed -install an overhead grab bar
 Prevents falling -install hand bars in bedroom and bathroom. use nonslip mats.
 Getting out of cair - use high seat chair


Railings or banisters placed in commonly used areas of the house may be of great benefit to the person experiencing difficulties with daily living activities. Special eating utensils may also be helpful.
2. Drug therapy
      There are 2 main types of drugs:
       1. symptom modifying helps to alleviate the symptoms but do not change the natural history of the conditions.
       depression:
       insomnia
       constipation,
       dysphagia,
       urinary frequency
      
       2. disease modifying drugs such as:
     
        Levodopa may be used to increase the body's supply of dopamine, which may improve movement and balance.
       Artane -is particularly good for reducing tremors
       Jumex-  is used in early Parkinson's Disease and helps reduce  bradykinesia
       Bromocriptine - enhance the effect of levadopa
       Deprenyl may provide some improvement to mildly affected patients.
       Amantadine or anticholinergic medications may be used to reduce early or mild tremors.
       Carbidopa reduces the side effects of levodopa and makes levodopa work better.
        Entacapone is used to prevent the breakdown of levodopa.
        Pramipexole and ropinirole are used before or together with levodopa.
        Rasagiline is approved for patients with early Parkinson's disease.  Rasagiline helps block the breakdown of dopamine.
        Neupro is a new skin patch that contains the drug rotigotine. This medicine helps dopamine receptors in the brain work better. The patch is replaced every 24 hours.
       
Additional medications to help reduce symptoms or control side effects of primary treatment medications include antihistamines, antidepressants, monoamine oxidase inhibitors (MAOIs), and others.


 It is important that the disease should be controlled before irreversible brain damage occurs.


3. Surgery:
In some cases surgery can help to alleviate symptoms especially when all other medications and measures failed.
Surgery to implant stimulators or destroy tremor-causing tissues may reduce symptoms in some people.
Transplantation of adrenal gland tissue and stem cells to the brain has been attempted, with variable results.

A Family Doctor's Tale - PSORIASIS

DOC I HAVE PSORIASIS

I have a patient who has psoriasis which need weekly injection of metathrexate to be done by me on the request of her dermatologist. Most of the time the the rashes are suppressed but when she is stressed the scaly rashes returned. Another patient had such bad psoriasis that even bending his joints hurts both because of the psoriatic arthritis as well as the split of the hard psoriatic skin.

Psoriasis is a disorder of the skin which typically consists of red patches covered by silvery-white scales especially around the trunk, elbows, knees and scalp.


There are five types, each with unique signs and symptoms.
1.Plaque psoriasis is the most common type of psoriasis. About 80% of people who develop psoriasis have plaque psoriasis, which appears as patches of raised, reddish skin covered by silvery-white scale. These patches, or plaques, frequently form on the elbows, knees, lower back,and scalp.


2.guttate psoriasis (small, red spots on the skin),


3.pustular psoriasis (white pustules surrounded by red skin),


4.inverse psoriasis (smooth, red lesions form in skin folds)


5.erythrodermic psoriasis (widespread redness, severe itching, and pain).


Psoriasis occurs about equally in males and females.
Recent studies show that there may be an ethnic link.
It seems that psoriasis is most common in Caucasians and slightly less common in African Americans.
Worldwide, psoriasis is most common in Scandinavia and other parts of northern Europe.
It appears to be far less common among Asians and is rare in Native Americans.


There also is a genetic component associated with psoriasis.
About one-third of people who develop psoriasis have at least one family member with the condition.


Research shows that the signs and symptoms of psoriasis usually appear between 15 and 35 years of age.
About 75% develop psoriasis before age 40.
However, it is possible to develop psoriasis at any age.
 After age 40, a peak onset period occurs between 50 and 60 years of age.


About 1 in 10 people develop psoriasis during childhood, and psoriasis can begin in infancy. The earlier the psoriasis appears, the more likely it is to be widespread and recurrent.


Its exact cause is unknown but the result is skin which grows about seven times more quickly and thicker than usual.
It is thought to be due, at least in part, to an abnormal immune reaction against some component of the skin.
Genetic factors play a part. About half those affected know of someone else in the family with it.


The rash often seems to start after some sort of trigger.
This may be emotional stress, skin injury (cuts and scratches for example), a streptococcal sore throat, hormones (it often occurs at puberty), or rarely, certain medications.
Psoriasis is not contagious.


Itchy, raised patches of dark pink skin.
White scales on the scalp, knees, elbows and upper body.

Pitting, discoloring and thickening of the fingernails and toenails.
Red, scaly and cracked skin on the palms of the hands or on the soles of the feet.
There may be fluid oozing out of the cracks and movement may become very painful.
The itching and discomfort may keep a person awake at night, and the pain can make everyday tasks difficult.


All types of psoriasis, ranging from mild to severe, can affect a person’s quality of life. Living with this lifelong condition can be physically and emotionally challenging.


Itching, soreness, and cracked and bleeding skin are common. Nail psoriasis can be painful.
Even the simple act of squeezing a tube of toothpaste can hurt.


Several studies have shown that people often feel frustrated.
In some cases, psoriasis limits activities and makes it difficult to perform job responsibilities.


Studies also have shown that stress, anxiety, loneliness, and low self-esteem are part of daily life for people living with psoriasis. One study found that thoughts of suicide are three times higher for psoriatics than the general population.


Embarrassment is another common feeling. Imagine getting your hair cut and noticing that the stylist or barber is visibly uncomfortable. What if you extended your hand to someone and the person recoiled? How would you feel if you spent most of your life trying to hide your skin?


Psoriasis is a chronic, meaning lifelong, condition because there is currently no cure. People often experience flares and remissions throughout their life. Controlling the signs and symptoms typically requires lifelong therapy.


Treatment depends on the severity and type of psoriasis. Some psoriasis is so mild that the person is unaware of the condition. A few develop such severe psoriasis that lesions cover most of the body and hospitalization is required. These represent the extremes. Most cases of psoriasis fall somewhere in between.


Topical medications (such as steroid and tar lotions, ointments, creams, and shampoo)
Phototherapy (either ultraviolet B, or UVB, radiation or psoralen with ultraviolet A, or PUVA, radiation)
Systemic therapy (oral drugs that affect the whole body system, not just the skin e.g. cyclosporins, methotrexate)


Combination are often used. These treatments are often given in the order described -- from least to most potent -- as necessary, although the physician may choose a more powerful therapy or use combination first if the patient's initial condition is severe.


With the emergence of several new therapies, including the biologic agents, more people are experiencing substantial improvements and reporting a greatly improved quality of life.

A Family Doctor's Tale - DANDRUFF

DOC I HAVE DANDRUFF

Dandruff is very frequent in many patients. However the number of patients who requests for treatment are low unless their dandruff are very bad. Most people would go for treatment by their hairdressers or beauticians.

Dandruff is an acute to chronic inflammatory scaly disease of the hairy areas of the scalp endowed with sebaceous glands.
As a result scales that are shedded from the the dead skin cells of the scalp are called dandruff or pityriasis capitis.


The cause of Dandruff is not completely known but are related to three possible factors:


1.Excessive sebaceous or oil gland secretions from the skin


2.the fungus Malassezia furfur has been known to be a poosible cause of dandruff. It metabolizes the oils present in sebum to a lipid byproduct oleic acid .This oleic acid can cause an inflammation in the epithelium of the scaly resulting in the shedding of dry scales.


3. allergic reaction to chemicals in hair oils, cream or gel
Certain oily foods may trigger the production of dandruff


Stress has been known to trigger off dandruff


Onset is usually gradual.
Symptoms:
1.Flaking of scales from the scalp.
2.Itchiness of the scalp
3.Redness of the skin on scalp, forehead and eyebrows


Signs:
1.Dry, rounded, greyish macular or papular lesions on the scalp.
2.The surface consists of dry scales which can be rubbed off
3.Sometimes the lesions can become crusted
4.Some lesions may become purulent with yellow exudate.


1.Dandruff shampoo such as Sebutone, Genisol, Selsun will help to remove flakes and reduce the lesions.


2.fungus infection  should be treated with antifungal orally and topical antifungal lotion and shampoo such as salicylate acid lotion, nizoral or ketoconazole shampoo.


3.For more severe cases with bacterial infection a combination of hydrocortisone and tetracycline ointment can be used to remove infected crusts.


4.General hair hygiene -
shampoo hair daily
Avoid too strong hair cream or gels


Generally good with treatment.


However recurrences are not uncommon.


General hair hygiene is important.

A Family Doctor's Tale - SCABIES

DOC I HAVE SCABIES

Scabies is a common disease in many patients often misdiagnosed for eczema. However the typical skin burrows appearance is very indicative of scabies. More commonly is lice infestation especially in the 1970 and 1980 where the nits are present on the hairs of many schoolgirls and rashes present on the under part of the thighs especially when sitting on wooden chairs or benches.
Treatment is the same as for scabies.

Scabies is a contagious skin disease caused by the mite Sarcoptes scabiei characterised by intraepidermal burrows,itchiness and secondary infections.
The female mite burrows into the skin and deposits her eggs and faeces.
The eggs hatch in 3-4 days into larvae which then becomes nymphs,moulting to adults in 14 days.
The skin becomes extremely itchy and red lesions appear in the skin.  Nursing homes are ideal breeding grounds for the parasite, which needs a human host to survive.


1.itching which is worse at night
2.characteristic burrow lines on the skin with papule at one end.
3.rashes and abrasions on the skin due to scratching and secondary infections.


Skin scrapings can be examined microscopically fot the scabies parasite.


Scabicides (chemicals to treat scabies) include:


Benzyl benzoate lotion
Gamma benzene hexachloride cream
Permethrin cream
Malathion lotion


Bathing is followed by application of the scabicide to the whole body from the neck to soles, left for 24 hours.
For some children under 2 years, the elderly in rest homes and others with reduced resistance, the scalp and face also needs to be treated.
A single overnight application of the scabicide(8 hours)  is washed off the following morning .
A second application four to seven days later is often recommended.


Treatment of contacts may be required if there is obvious signs of scabies.


While the scabies mite cannot live off the human skin for longer than 24 hours, each treatment with scabicide should be accompanied by washing, in hot water, of bedsheets, pillow cases and any clothes worn over the previous week.


Most people improve within a few days of treatment but it may take 4-6 weeks for the itch and rash of scabies to go away completely.

A Family Doctor's Tale - VULVITIS

DOC I HAVE VULVITIS

Vulvitis is very common in all women. They either complain of itch or pain or excessive discharge of the vulva area.Infection may due to dirty hands, poor personal hygiene, excess menstruation or due to their sexual partner.It is frequently seen in a family practice both in children and adults.The most recent case was of that of a large bartholin cyst infection who was sent to the gynecologist for surgical treatment.


Vulvitis is an acute inflammation og the vulva in females.


Vulvitis is usually caused by the following:


Infections:
1.sexually transmitted disease like gonorrhea,trichomonas and chlamydia.
2.Fungal infection such as candidiasis
3.Herpes simplex in recurrent cases
4.Pediculosis pubis or lice
5.pinworm infection in children
6.Urinary infection such as cystitis


Allergies:
1.Clothings
2.perfumes
3.powders
4.drugs


Chemical irritants:
1.vaginal douche
2.detergents used to wash underwear


Mechanical irritants:
ill fitting underwear
inadequate sexual lubrication


Postmenopausal:
Atrophic vulvovaginitis after menopausal with dryness and inflammation


Generalised disorders:
Dermatological disorders such as lichen simplex


Persons who has Acute Vulvitis has the following
Symptoms:


1.vulval irritation and itch
2.discharge from vagina
3.painful or frequency of urination
4.excoriation of the inner lining of vulva


Signs:
1.discharge can be seen in female vagina
2.redness and inflammation of the vulva


Diagnosis can usually be made by :
1.History of vulval itch associated frequency of urination, painful urination or discharge from vagina


2.Vulva shows inflammation, excoriation of lining,


3.Vulval and vaginal swab to culture for bacteria and sexually transmitted organisms and the antibiotic most appropriate for it.


4. biopsy of the suspicious vulval lesions to exclude other causes of vulval problem such as tumor


1.Approprate Antibiotics, antifungal for infections especially after urine bacterial culture
2.Antihistamine medicine for itch
3.Topical oestrogen cream for postmenopausal atrophic vulvovaginitis
4.Proper hygience after urination, sexual intercourse and bathing
5.Avoid strong soaps
6.Use of lubricants during sexual intercourse
7.Weight reduction if obese
8.Treat underlying condition such as diabetes,allergic dermatitis,other skin conditions.


Prognosis is usually good with medication.
Sexual partner may need to be treated.
Recurrence is quite common.

A Family Doctor's Tale - CANDIDIASIS

DOC I HAVE YEAST INFECTION

candida fungus

Candidiasis is a very common infection in men and women usually spread by sexual intercourse. It presents as itchy rashes on the penis or in the vulva and vaginal area. It can also be caused by the wetness of the vulval and vaginal area due to sweat or menstrual bleeding followed by discharge.

Candidiasis is caused usually by the fungus Candida albicans.
Other Candida species or yeasts are also responsible.


What are the causes
1. Antibiotic therapy
2. Diabetes
3. Steroid or immunosuppressive drugs.


30% of patients do not have any symptoms.
The rest have symptoms like:


1. pruritus,
2.vaginal soreness,
3.dyspareunia,
4.external dysuria, and
5.abnormal white transparent vaginal dischargewoth heavy odour
About 75% of women will have at least one episode of Candidiasis, and 45% may have two or more episodes.


A diagnosis of Candida vaginitis is made clinically by the presence of:
1.external dysuria and
2.vulvar pruritis, pain, swelling, and redness.
3. vulvar edema, fissures, excoriations, or
4.thick curdy vaginal discharge.


The diagnosis is confirmed by
1) a Gram stain of vaginal discharge shows yeasts
2) a vaginal swab for culture shows the presence of a yeast species. Candida vaginitis is associated with a normal vaginal pH (<4.5).


Short-course intravaginal antifungal pessaries effectively treat uncomplicated Candidiasis .
The topically applied imidazole drugs are more effective than nystatin.
90% of patients are usually cured.


Oral Agent such as Fluconazole 150 mg may be given in  one tablet in single dose.


Patients should be instructed to return for follow-up visits only if symptoms persist.


Candidiasis is not usually acquired through sexual intercourse.
A minority of male sex partners might have balanitis, which is characterized by itchy red areas on the glans of the penis.
These men benefit from treatment with topical antifungal agents to relieve symptoms.


Topical agents usually do cause any systemic side effects although in some people local burning or irritation might occur.
Oral agents occasionally cause nausea, abdominal pain, and headache. Some abnormal elevations of liver enzymes may occur with treatment with the oral azoles.


A small percentage of women (<5%) has recurrences of Candidiasis 4-5 time in a year.
The majority of women with recurring Candidiasis have no apparent predisposing or underlying conditions.
Vaginal cultures should be obtained from these patients to confirm the clinical diagnosis and to identify unusual species, including nonalbicans species, particularly Candida glabrata Conventional antimycotic therapies are not as effective against these species as against C. albicans.


A longer duration of initial therapy is necessary to attempt mycologic remission before initiating a maintenance antifungal regimen.


Maintenance Regimens


Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the first line of treatment. If this regimen is not feasible, some specialists recommend topical clotrimazole 200 mg twice a week, clotrimazole (500-mg dose vaginal suppositories once weekly), or other topical treatments used intermittently.


Suppressive maintenance antifungal therapies are effective in reducing RVVC. However, 30%–50% of women will have recurrent disease after maintenance therapy is discontinued. Routine treatment of sex partners is controversial. C. albicans azole resistance is rare in vaginal isolates, and susceptibility testing is usually not warranted for individual treatment guidance.

A Family Doctor's Tale - CHLAMYDIA

DOC I HAVE CHLAMYDIA

Recently I have a patient who was tested for sexually transmitted diseases. The result came back as positive for chlamydia. He was treated for Chlamydia for 10 days as well as his wife and girl friend. After 1 month he was again tested for sexually transmitted disease. His results came as negative for all venereal disease including HIV and Chlamydia. He was happy with the results. Chlamydia is a disease which can be treated easily.Having his wife and girlfriend treated was the right thing to do as chlamydia can be spread easily through sexual intercource.

Chlamydia is a bacterial infection which is one of the most common sexually transmitted diseases.

It used to be called lymphogranuloma venereum because of the typically enlarged lymph nodes at the groins.

It can lead to pelvic inflammatory disease (PID), as well as sterility and pregnancy problems.


Chlamydia is highly contagious.
It spreads by sexual contact with an infected partner.


It can also be transmitted from mother to child during birth.
This may lead to an infection of the eyes and lungs in the infant.


It is also be transmitted through casual sexual contact with other people.


About 80% of women and 10% of men display no symptoms.


For the rest the symptoms often appear 7-14 days after transmission in the following ways:


For men:

1.Discharge from a papule on the penis

2.Burning pain and itching when urinating.

3.lymph nodes enlargement at inguinal regions

4. Anal infections in homosexuals

Symptoms present early a few days after exposure, go away, only to return.

Advanced Chlamydia infection may lead to inflammation of the sperm duct (epididymitis), proctitis (anal region) and sterility.

For women:

1.Vaginal itching or discharge.

2.Abdominal pain,

3.Bleeding between menstrual periods

4.Low grade fever

5.Anal infections

The disease can also cause cervicitis, endometritis and pelvic inflammatory disease which can result in sterility.


For infants:

1.Fever

2.Pneumonia

3.Conjunctivitis

Symptoms usually show up one week to one month after exposure.


Besides the above symptoms, headache, conjunctivitis, skin rashes, nausea and vomiting can be present.


Women may be tested through the insertion of a swab into the cervix during a pelvic exam.


Men can be examined by inserting a swab into the urethra to take a specimen.


Urine testing can also be done for both sexes.


Blood test for chlamydia can also be done.


Early treatment is important as it can protect against problems like pelvic inflammatory disease as well as sterility and pregnancy problems.

Patients typically undergo antibiotic treatment (usually tetracycline or sulphonamides) for a week.
The medication can be taken orally.
This treatment must be followed through even when symptoms of Chlamydia disappear.

Alcohol should be avoided when taking antibiotics, as well as milk and other dairy products.


Where Chlamydia has been transmitted through sexual contact, it is essential that both sexual partners are treated for the disease.


It is recommended that both partners abstain from sexual activity from the time of diagnosis until they have completed treatment.


Follow-up treatment is also important, as doctors need to make sure the infection has been cured.


The best way to prevent Chlamydia is through improved hygiene standards and lifestyle changes.


Sexually active persons should use condoms.


Abstinence is recommended for those infected and on antibiotic treatment.

One's risk for Chlamydia, or any other sexually transmitted disease, increases with the number of sexual partners.
Prevention is always better than cure!

A Family Doctor's Tale - URETHRITIS

DOC I HAVE URETHRITIS

Every now and then you will get a male patient who had painful pus discharge from his penis usually on the 2nd or 3rd day of having a sexual relationship with a prostitute or some social escort either in the local red light district or in another country. He will be advised to have a blood tests to exclude other sexually transmitted diseases. He will be give some antibiotic which can clear gonorrhea, chlamydia and other bacteria infection. The problem is the viral diseases such as HIV and herpes which may not be curable.

Urethritis is an acute infection of the urethra(tube which allows passage of urine from the bladder to the outside).


Urethritis is usually caused by the following:

1.sexually transmitted disease like gonorrhea and chlamydia.
2.Urinary infection such as cystitis
3.In males associated with prostatitis

4.Urinary stone stuck in the urethra may cause urethritis
6.urinary catheterization
7.Injury to the urethra
8.Important component of Reiter's Syndrome


Persons who has Acute Urethritis has the following symptoms:

1.painful urination
2.purulent discharge from penis in males or vagina in females
3.frequency of urination
4.cloudy and unpleasant smelling urine, sometimes blood in the urine
5.fever and chills
6.Polyarthritis and conjunctivitis in Reiter's Syndrome


Signs:
1. pus discharge can be seen in male's urethra or in female vagina
2.redness and inflammation of the opening of the urethra


Diagnosis can usually be made by :
1.History of sexual activity followed by frequency of urination, painful urination or pussy discharge from urethra or vagina


2.Urine test shows the presence of pus cells, leukocyte, red blood cells and micro-organisms


3.Urine culture for bacteria and sexually transmitted organisms and the antibiotic most appropriate for it.


4. cystoscopy may be necessary to exclude urinary stones, tumors of the bladder in the case of blood in the urine


Complications are from upward infections from the urethra  leading to infections of the bladder and kidneys.


Treatment of Urethritis:

Analgesic medicine for pain
Appropriate Antibiotics for infections especially after urine bacterial culture
Lots of fluids



Prognosis is usually good with medication.
Sexual partner may need to be treated.
Recurrence is quite common.

A Family Doctor's Tale - HIV

DOC I HAVE HIV INFECTION

HIV the word itself strikes in every person because there is no cure for it at the moment and also it is sexually transmitted. Like leprosy before, any one with HIV infection is avoided which is why the AIDS red ribbon  campaign was born to educate and pass information on AIDS and HIV infection. It is not easy to pass HIV infection to some one except through sex and blood transmission(infected needles through injection of drugs or blood transfusion.

AIDS is an acronym for Acquired Immune Deficiency Syndrome which is the final and most serious stage of HIV. 
HIV stands for the Human Immunodeficiency Virus which can cause a person infected with it up to 10 years to develop AIDS.


HIV is transmitted by:

1.unprotected sexual intercourse with an infected person
2.the sharing of HIV-tainted needles and instruments
3.from a mother to her baby, while pregnant, at birth, or through breastfeeding
4.receiving infected blood and blood products (e.g. organs, plasma).


The HIV infection destroys CD4 (T-cell) lymphocytes and thus weakens the body's immune defence. The T-cells are white blood cells which helps to protect the body from bacteria, viruses and harmful germs.


If the T-cells are destroyed or weakened, they are less able to defend the body effectively against infections. Having HIV also increases the risk of getting cancers. The HIV virus can attack every organ of the body.


AIDS which is the terminal stage of HIV infection is fatal. Once you reach this stage, the person usually dies 1-3 years from various infections and cancers.


Usually, a HIV-infected person may not notice any symptoms.
However, the following symptoms may be experienced:

1.fever
2.sore throat
3.muscular stiffness or aching
4.headache
5.diarrhea
6.swollen lymph glands
7.fatigue
8.rash of various types
9.joint pain


Blood test for HIV Antibodies.
A negative result does not necessary mean you do not have HIV.
There is a mirror period of 1-3 months sometimes before the HIV antibodies show positive results.
When a test shows positive results, the blood is retested at a CDC(Communicable Disease Center) which is able to test quantitative results for HIV.(Western Blot HIV Confirmatory Test)


So far in my 37 years of family practice, I have come across 2 cases of positive HIV tests. One was a Filipino maid  whose employer was so worried about her family that I decided to send her to the Communicable Disease Center to stay bfore she was repatriated to Phillipines.
The other was a Malaysian elderly man who spent all his wealth on prostitutes. His daughter brought him to me for a complete blood tests. Her worst fears was confirmed when he was diagnosed with positive HIV. He was sent back to Malaysia for treatment.
 

Rapid HIV testing through nose swabs is now offered in some medical clinics. These tests produce very quick results. In approximately 20 minutes you may be able to know your HIV status.


At the present moment there is no cure for HIV or AIDS.
Treatments which can improve the patient’s immune system and prevent the onset of AIDS however are available:


1.Reverse transcriptase (RT) inhibitors:
This first group of drugs approved to treat HIV infection act by preventing the replication of the HIV virus.The HIV virus is unable to spread in the body so easily and less secondary infection may attack the body.


2.Protease inhibitors:
This second class of drugs act by stopping the replication of HIV at a later stage in the cycle.


3.Combination or cocktail therapy (using two or more drugs together) is preferred in case the HIV virus becomes resistant to both classes of drugs. 

4. New uses of thalidomide and anti malaria drugs have being tried with good results on AIDS patients.


Prevention of HIV infection are by:

1.remain in a monogamous relationship.


2.always practice safe sex by using condoms consistently and correctly. Note that condoms do not give 100% protection from HIV.

A Family Doctor's Tale - DENGUE

Aedes mosquito

DOC I HAVE DENGUE FEVER

Dengue fever is a acute viral infection caused by the dengue virus which is transmitted by the bite of an infected female Aedes mosquito.


The dengue virus has 4 strains called serotypes 1, 2, 3 and 4.
An infection with one serotype does not protect you from the other serotypes.
A second dengue infection, especially with serotype 2, can cause aneven worse infection such as Dengue Haemorrhagic Fever and Dengue Shock Syndrome which can be fatal.


The incubation period in mosquito is 8-12 days and 3-14 days in humans.
Symptoms usually last 3-14 days.


1.High, acute, prolonged fever (usually lasts for 5 to 7 days)
2.Severe headache
3.Pain behind the eyes
4.Muscle and joint pains
5.Rashes
6.Nausea , vomiting
7.Abdominal discomfort
8.Loss of appetite
9.Fatigue
10.Diarrhoea


A rash usually appears 3-4 days after the fever.
There are 3 types of dengue rash.
1.Petechial Rash:
----------------
This is the most common with the petechial rash appearing as red dots under the skin.
The rashes are usually found on the limbs  and lower abdomen and is due to the bleeding under the skin.


2.Diffuse erythematous rash with areas of normal skin:
----------------------------------------------------
The whole skin becomes reddish with scattered, small areas of normal skin .


3.Maculopapular rash:
--------------------
The last type of rash appears as red flat or raised lesions (Maculopaular).
The rash can be itchy .


The complications of Dengue Fever are:


1.Dengue Hemorrhagic Fever
a. Fever
b.bleeding likely to occur from the nose, mouth, and gums.
Bruises and ecchymosis may appear as a sign of bleeding under the skin.
There are small red spots on the skin.
c.the urine may contain blood.
d. vomiting of blood and melena(black stools) indicate bleeding in the stomach.
e.low platelet count of <100,000
f. Hypoalbuminaemia
g.pleural effusion
h.neurological disturbances(seizures,cranial nerve signs and coma) may indicate bleeding in the brain


2. Dengue Shock Syndrome
Without prompt treatment for the bleeding, the person can go into a.shock
b.hypotension
c.narrowed pulse pressure(< 2omm Hg)
d. impaired organ perfusion which result in organ failure and death.


 Dengue Haemorrhagic Fever and Dengue Shock Syndrome is fatal in about 5 percent of the cases, mostly among children and young adults.


History of mosquito bite,acute fever and bleeding signs
A low platelet count (<100,000)is suggestive of dengue fever.
Specific blood test(IgG and IgM antibody) for dengue virus can also be conducted. IgM antibodies occur on the 5th day of illness and last for 2 months.


There is no specific anti-viral drug to treat the disease or a vaccine to prevent a person from being infected with the dengue virus.
Treatment is mainly supportive.
1. Rest
2.drinking lots of water to prevent dehydration will help.
3. Paracetamol for fever, severe headaches and body aches( Avoid aspirin and NSAIDs due to the risk of bleeding) to reduce the discomfort.
4. Intravenous fluids for hypotension and dehydration.
5.Daily blood tests (platelets and hematocrit)may be necessary to monitor the risk of bleeding
6. Platelets transfusion when the the platelet count is less than 20,000.


The illness can last up to 10 days, but complete recovery can take as long as a month.


Dengue Fever is spread only through the bite of the infected Aedes mosquitoes.


The transmission cycle for dengue starts when:


1.Infected Aedes mosquito bites a healthy person.
2.4-7 days later,the infected person develops fever
3..When fever starts, the person is infectious for about 5 days.
4.If an Aedes mosquito bites the person during this time when he is infectious, it will be infected by the the dengue virus.
5.The virus will multiply in the second mosquito for 5-7 days.
6.The mosquito then becomes infective.
7.The cycle starts again when it bites another person.


To prevent dengue fever, you must prevent the breeding of its carrier, the Aedes mosquitoes, identified by their black and white stripes on the body .
A puddle of water about the size and depth of 20-cent coin is sufficient for an Aedes mosquito to breed in.


The Aedes mosquitoes are commonly found breeding in clear stagnant water in flower vases, flower pot plates, roof gutters, earthen jars for water storage or decorative purposes, watering cans, and bamboo pole holders.


The Aedes mosquito can also breed in unusual places such as water trapped in the hardened soil in potted plates, and the rim of unwanted pails


Every other day
Change water in flower vases.
Scrub the inside of vase to remove mosquito eggs filling in fresh water.
Remove water in plant pot plates.
Scrub the plate thoroughly to remove mosquito eggs.
Clear fallen leaves and stagnant water in drains and garden. Some leaves can collect water.
Once a month
Add prescribed amounts of sand granular insecticide into containers, vases, gully traps and roof gutters, even if they are dry.


Sand granular insecticide can be purchased from plant nurseries and DIY stores. (Caution: Do not add the chemical into drinking water. Keep out of reach of children.)
Clear away leaves in roof gutters and apron drains.
Remove roof gutters wherever feasible.
At all times Turn pails and watering cans over and store them under shelter.
Place/ store all articles that can collect rain water under shelter at all times.
Cover bamboo pole holders when they are not in use.
Cover rarely used gully traps.
If possible, replace gully trap covers with non-perforated ones and install anti-mosquito valves.
Do not block the flow of water in scupper drains along common corridors in appartments.
Do not place potted plants and other paraphernalia over the drains.
Do not litter.
Paper cups and water bottles thrown indiscriminately into drains, grass verges, roadside, vacant lands and other public places can collect rainwater and breed mosquitoes.


If you are vacating your home or away on long holiday


Cover the toilet bowls.
Seal off the overflow pipe of the flushing cistern.
Cover all gully and floor traps.

A Family Doctor's Tale - HEPATITIS B

DOC I HAVE HEPATITIS B

Hepatitis B carriers are found in most family clinics as a result of better testing. One mother I saw frequently only found that she had Hepatitis B Antigen only after her second child was born. Her husband and older child were tested by me and found to be free of Hepatitis B. Both of them were vaccinated against Hepatitis B and still have antibodies in them after 10 years. The mother was tested for her liver function test and alpha fetal protein ( a cancer marker for Liver Cancer) every 6 months. So far she is fine. But there are many Hepatitis B carriers who developed Liver Cancer later on in life.

Hepatitis B ( A Simple Guide to Hepatitis B)is a serious chronic inflammatory liver disease caused by a virus which is called hepatitis B virus (HBV).


Most of the time a person with HBV infection has no symptoms at all.
Older people are more likely to have symptoms.


If you have symptoms, they might include :

1.jaundice (yellowing of the skin and white of eye)
2.dark colored urine
3.pale stools
4.prolonged tiredness
5.nausea and vomiting.
6.poor appetite
7.abdominal pain
8.fever and joint pains


A blood test is the only way to diagnose hepatitis B.
You may be infected with HBV and may even spread it to others without knowing it.
HBV can be spread from an infected mother to her infant during birth. To prevent spread of HBV from infected mothers to their infants, every woman should have her blood tested for hepatitis B surface antigen (HBsAg) during each pregnancy.


There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs eg interferon which may be able to treat chronic HBV infection.


If you have never been immunized or do not have antibodies from having a previous Hepatitis B infection, you are at risk of Hepatitis B infection.


The Hepatitis B virus is is not spread through food or water, sharing eating utensils, breastfeeding, hugging, coughing, sneezing, or skin contact.

HBV is spread by exposure to infected blood from skin puncture or contact with mucous membranes.


It is spread by:
1.sexual contact with an infected person
2.an infected mother to her newborn during childbirth
3.a Hepatitis B infected person's blood during blood transfusion
4.sharing of injection needles among drug abusers
5.accidental cuts to the skin by a nail clipper, shaving blade or other instruments that are contaminated with a Hepatitis B infected person's blood
6.contact with an infected person's saliva or blood through cuts or sores in the mouth or skin.
7.during acupuncture, body or ear piercing  and tattooing if the needles used are contaminated with Hepatitis B infected person's blood
8.occupational contact with human blood or body fluids


Hepatitis B vaccine is the best prevention against hepatitis B. If you do not have antibodies from a previous infection and if you are not a Hepatitis B carrier, you can get vaccinated against Hepatitis B and protect yourself from its complications.


When the first Hepatitis B vaccine first came out about 20 plus years ago, it was made from serum obtained from patients with hepatitis B virus infection. There was a fear of catching other illness like HIV from it. It cost about $120 per injection. Now it   is made using a synthetic recombinant DNA technology which has no blood from carriers. There is no way that you will catch hepatitis B or HIV from this new vaccine. The price has also drop to $25 per injection.

Hepatitis B vaccine is recommended for all infants, for children and adolescents who were not vaccinated as infants, and for all unvaccinated adults who are at risk for HBV infection as well as any adult who wants to be protected against HBV infection.
The vaccine is safe. It is also extremely effective provided you complete all 3 doses:


1st dose - at the appointed date
2nd dose - 1 month after the 1st dose
3rd dose - 5 months after the 2nd dose


Infants born to infected mothers need to get hepatitis B vaccine and another shot call HBIG (hepatitis B immune globulin) soon after birth to prevent infection.


Besides vaccination,other ways to prevent transmission of HBV are:

1.avoid multiple sexual partners; keep to one sexual partner
2.Latex condoms, when used consistently and correctly, may reduce the risk of sexually transmitted HBV transmission.
3.Do not inject illegal drugs. Never share needles, syringes or drugs.
4.do not share personal items like razors, toothbrushes or any other instruments that may cause  tears to the skin and hence spread of any blood borne infection.
5.seek reliable operators for ear or body piercing, tattooing or acupuncture.


Hepatitis B carriers will need to do the following:
1.you will need to see your doctor every 6 months to a year for tests to check your liver function and blood alpha-foetoprotein which is a cancer marker for liver cancer
2.your immediate family members should go for blood tests. They should  get immunized if they are not immune. If they are carriers too, they should go for regular follow up with the doctor.
3.you should take precautions to prevent the spread of hepatitis B to your family and loved ones
4.you should avoid smoking and drinking alcohol as they may further increase the risk of damage to your liver
5.inform your doctor and dentist that you are a carrier
6.do not donate blood, organs or sperm
7.know the symptoms and signs of the various complications and see your doctor at once if you experience any of them.


Hepatitis B can lead to complications like:


1.acute hepatitis (episode of liver inflammation)
2.chronic hepatitis (permanent liver inflammation)
3.liver cirrhosis (permanent scarring and hardening of the liver)
4.liver failure (liver is unable to function,resulting in toxins accumulating in body)
5.liver cancer


Those who recover completely from Hepatitis B infection become immune to the disease.
1 in 10 people who get infected with the virus become carriers who then carries the Hepatitis B virus permanently in his body. 

Hepatitis B carriers seldom show any symptoms but they can:

1.spread the disease to others
2.develop serious liver complications such as those mentioned above.


About 15%-25% of people with chronic HBV infection die prematurely from these complications.