RABIES SYMPTOMS AND TREATMENT

Portuguese version: RAIVA HUMANA

Rabies is a zoonosis (a disease transmitted from animals to humans) caused by a virus. It is one of the most serious diseases known. The mortality is almost 100%. No other infectious disease has a mortality rate as high. Although there is an effective vaccine, each year approximately 70,000 people worldwide still die from rabies.

The rabies virus is transmitted by bites and scratches from infected mammals. In most cases the transmission occurs through dogs and cats. However, several other mammals can transmit the disease, including:

- Ferrets
- Foxes
- Coyotes
- Raccoons
- Skunks
- Bats

Rodents such as squirrels, rats, rabbits and hamsters are not common transmitters of rabies. There are very few human cases caused by one of them.

Non-mammalian animals such as lizards, fish and birds DO NOT transmit rabies.

Symptoms of rabies

The rabies virus has tropism for the central nervous system, i.e, it is a neuroinvasive viral disease that causes acute encephalitis (inflammation of the brain).

Symptoms of rabies are all due to this involvement of the brain:

- Confusion
- Disorientation
- Aggressiveness
- Hallucinations
- Difficulty swallowing
- Motor paralysis
- Seizures
- Excessive salivation

Once started the neurological symptoms, the patient progresses to death in 99.99% of cases. To date (September 2009), that are only 3 reported cases where the patient survived. These three cases are the result of a new treatment regimen first described in 2005 which includes an antiviral (Ribavirin), an anesthetic (Ketamine) and an anxiolytic (Midazolan). However, despite the cure, the sequels are severe.

The evolution of rabies can be divided into 4 stages:

1.) Incubation – The virus spreads through the peripheral nerves slowly. From the bite to the onset of neurological symptoms there is usually a range of 1 to 3 months.

2.) Prodromes – They are non-specific symptoms that occur prior to encephalitis. Usually consists of headache, malaise, fever, sore throat and vomiting. There may also be numbness, pain and itching at the site of the bite or scratch.

3.) Encephalitis – is the manifestation of inflammation of the central nervous system as previously described.

4.) Coma and death – Occur on average 2 weeks after the onset of symptoms.

Treatment of rabies

If on one hand virtually 100% of patients die after the onset of symptoms, on the other, there is a vaccine and a prophylactic treatment with immunoglobulins (antibodies) in the event of exposure to the virus.

If bitten by a mammal, you should wash the wound with soap and water and move toward a health facility.

If the animal is domestic is important to know its vaccination data. It must be attested that the dog or cat is immunized against rabies. In domestic animals, the incubation period is usually within 10 days. This is the period in which the animal must be observed. If after 10 days it remains healthy, there is no risk of contracting rabies.

If the animal is wild like a bat, it is important to capture it, so it can be analyzed. If you can not capture the animal, the treatment should be started assuming that it has rabies. The same goes for street dogs and cats that manage to escape.

Bites on the head and neck are the most serious ones, because they are close to the brain. In this case, the travel length to the brain is much shorter than, say, a bite on the legs.

Unless there is an open sore on the skin, one cannot get rabies only from touching or being licked by an animal. But the old habit of offering wounds to be licked by a dog, not only facilitates a bacterial infection, as it can also transmit rabies, given that the virus resides on the animal’s saliva.

The post-exposure prophylaxis (after bites from suspected animals ) should be started as soon as possible. There are several schemes involving vaccines and immunoglobulins. Depending on the severity of the injury, the schema can include up to 10 days of vaccination followed by daily administration of immunoglobulin.

It is also important to get immunized against tetanus, if the last vaccination has more than 10 years. In addition to tetanus and rabies, animal bites can become infected and antibiotics may be necessary.

Bites from Bats

Bats are animals commonly infected by rabies. In the U.S. the past 15 years, more than 90% of rabies cases were caused by bat bites.

The big problem is that the bite may go unnoticed, especially if it occurs while the victim sleeps. Therefore, treatment is indicated for those who wake up and find a bat in your room, even with no signs of bite or scratch. As rabies is very lethal, when in doubt, you should always assume that the bite has happened.

It is important to understand the seriousness of rabies. You should never overlook a bite or scratch by animals. Do not rely solely on the appearance of the animal to determine that it is not sick. Once bitten, you should seek medical assistance immediately.

What Is Polycystic Kidney Disease? – Get All The Key Facts

Polycystic kidney disease is a genetic disorder where clusters of cysts grow primarily in the kidneys, the organs responsible for filtering waste and excess fluid from the blood. These cysts are filled with fluid and can cause the kidneys to become enlarged. Eventually, the cysts can take over the kidneys and impair their function, leading to kidney failure.

What Causes It

Polycystic kidney disease (PKD) is inherited. The most common form is autosomal dominant PKD, accounting for approximately 90 percent of all PKD cases. Symptoms of autosomal dominant PKD most often occur after the age of 30. Autosomal recessive PKD is rarer with symptoms showing up early, in some cases in the womb.

Symptoms

This form of kidney disease produces several symptoms, including many that are present with other forms of kidney disease. They include:

- Anemia – Blood in the urine – Enlarged abdomen – Headaches – Hemorrhoids – High blood pressure – Impaired growth – Irregular urination – Kidney failure – Kidney stones – Urinary tract or kidney infections – Varicose veins

Complications

If you have polycystic kidney disease you have a high risk of developing hypertension or high blood pressure. Hypertension further damages the kidneys and increases your likelihood of developing a cardiovascular problem such as an aneurysm or heart valve abnormality.

As the disease progresses, polycystic kidney disease may cause cysts to grow in the liver, heart or brain as well. It may also cause complications during pregnancy or lead to diverticulosis — bulging sacs in the colon.

Diagnosis

In many cases, PKD doesn’t produce symptoms early on, so blood or urine tests aren’t as reliable initially for diagnosis. Instead, polycystic kidney disease is usually diagnosed through medical imaging technology, which can pick up the cysts once they reach about half an inch in size.

Ultrasound tests are the most frequent tests used for diagnosis, and can diagnose cysts even in a foetus. However, computerized tomography (CT) scans and magnetic resonance imaging (MRI) are more powerful tests that may also be used. These tests can help to assess the progression of the disease.

Treatment

Reducing high blood pressure is essential when you have polycystic kidney disease. This step helps to limit the amount of damage to your kidneys, and delays or prevents complications of PKD such as cardiovascular problems or anemia. There are several natural ways to lower your blood pressure, including exercising daily, eliminating salt from your diet, or taking nutritional and herbal supplements.

Your doctor may also recommend having the kidney cysts drained or removed. If you develop a kidney, bladder or urinary tract infection you may need to take antibiotics. Also, hormone replacement therapy is not recommended when you have polycystic kidney disease.

If PKD becomes advanced you may develop kidney failure which means you may need to undergo dialysis or have a kidney transplant. The use of natural therapies can help to reverse and prevent kidney damage, including polycystic kidneys. This is includes nutritional supplements, herbs and dietary and lifestyle changes. If incorporated correctly these not only help to relieve symptoms but can also remove the cause of kidney damage.

UNDERSTAND HYPERTENSION (HIGH BLOOD PRESSURE)

Spanish version: SÍNTOMAS Y TRATAMIENTO DE LA HIPERTENSIÓN ARTERIAL
Portuguese version: SINTOMAS E TRATAMENTO DA HIPERTENSÃO

One of the major problems of hypertension (high blood pressure) is the fact that it is asymptomatic until advanced stages. To assume that the pressure is high or normal based on symptoms such as headache, fatigue, pain in the neck or eyes, feeling of heaviness in the legs or palpitations, is a very common mistake among patients.

Another mistake is to evaluate the blood pressure based only in one isolated measure. A hypertensive patient may have times of day when the pressure is within or near the normal range, as well as, a person without hypertension may have high pressure due to factors such as stress and physical exertion. So we do not make the diagnosis or rule out hypertension based on only one measure.

Several factors can alter the pressure from time to time, among them are stress, physical exertion, use of alcohol or cigarettes etc … People tend to measure the blood pressure after events of emotional stress or headache, situations which in itself can increase its levels.

To make the diagnosis of hypertension we need from 3 to 6 high measurements carried out on different days, with a range greater than 1 month between the first and last measurement. This way, we minimize the confounding external factors.

If after that there is still doubt, the ideal is to request an ABPM (Ambulatory Blood Pressure Monitoring). The ABPM is basically a blood pressure device, which is in the patient’s arm for 24 hours, checking his blood pressure several times a day, covering all common daily situations such as sleeping, eating, working etc …

Persons with over 50% of measurements above normal range are considered hypertensive. Between 20% and 40% are people at high risk of developing hypertension, which already implicate changes in lifestyle and diet. Normal people have controlled pressure by more than 80% time of the day.

The most accepted definition on hypertension today is as follows:

Normotensive: pressures less than or equal to 120/80 mmHg
Pre-hypertensive: pressures between 121/81 – 139/89 mmHg
Hypertensive grade I: pressures between 140/90 – 159/99 mmHg
Hypertensive grade II: Pressures greater than or equal to 160/100 mmHg

White coat hypertension

The white coat hypertension happens to patients who only have high blood pressure during medical visits. These are people who gets anxious in the presence of the physician and they’re pressure rises immediately. Sometimes it is difficult to differentiate them from true hypertension. In general it is necessary to perform the ABPM to be sure.

The white coat hypertension is not hypertension itself, but it affects people who are more likely to develop it. Therefore, the white coat hypertension is a risk factor for hypertension and also implicate real changes in lifestyle to prevent the progression of the established disease.

Hypertension is associated with several serious illnesses such as:

- Heart failure
- Myocardial infarction
- Cardiac arrhythmia
- Sudden Death
- Aneurysms
- Loss of vision (hypertensive retinopathy)
- Chronic renal failure
- Ischemic and hemorrhagic stroke
- Dementia micro infarcts.
- Arteriosclerosis

Hypertension is rarely curable and the goal of the treatment is to avoid that major organs as the heart, eyes, brain and kidneys don’t suffer injuries that will cause the diseases described above. These are the so-called target organs.

As already mentioned, the initial lesions of hypertension are asymptomatic, however, there are tests that can detect them early.

KIDNEY

An early manifestation of renal damage by high pressure is the presence of protein in urine, called proteinuria. These proteins can be detected easily through a simple urine dipstick test. Small amounts of protein cause no symptoms. Advanced renal lesions lead to major proteinurias, manifested as foamy urine. Another sign of advanced disease is the elevated blood level of creatinine.

High blood pressure untreated can, in the long term, lead to kidney failure and hemodialysis.

EYES

Hypertension leads to damage of blood vessels that irrigate the eyes causing progressive loss of vision. An examination of the eye by the ophthalmologist can reveal an early injury that hasn’t cause symptoms. It’s that simple test in which the doctor dilates the pupil and then observes the eye with a special flashlight.

Compare the 2 pictures below from an ophthalmoscopy. The first is a normal eye. The second is an eye with advanced hypertensive retinopathy. The red spots are hemorrhages, and the bright spots are pus secondary to the inflammation. Note the deformity of the vessels.

HEART

The heart is perhaps the organ which suffers the most from a high blood pressure. Hypertension make it harder for the heart to pump the blood as there is a high resistance to overcome. The heart is a muscle and as such it becomes hypertrophied (increased muscle mass) when subjected to chronic stress. A heart with increased muscle mass, has a smaller space in its cavity to receive blood. This is called diastolic dysfunction.

Therefore, left ventricular hypertrophy and diastolic dysfunction are the earliest signs of cardiac stress by hypertension. It can be detected on a electrocardiogram, but are best seen on an echocardiography.

Like a rubber band that for a long time has been strained and lost its elasticity, getting loose, the heart after years of stress on high blood pressure begins to dilate and lose the ability to pump blood. To this stage is given the name of heart failure.

BRAIN

One of the most important risk factors for stroke is hypertension.

The hypertension can lead to small repeated strokes that do not cause major neurological sequel at first. As time passes and hypertension is not controlled, these small lesions will multiply, being responsible for the deaths of thousands of neurons. The patient begins to present a progressive state of loss of his intellectual abilities that often go unnoticed by the family in the early stages, but in the end, it leads to a state called multi-infarct dementia or vascular dementia.

Most often target organs lesions can be reversed if treated in time. But for this, it’s necessary to be aware that hypertension should be treated before symptoms of target organ lesions appear, and not after.

The main risk factors for hypertension are:

- African American
- Obesity
- High consumption of salt
- Consumption of alcohol
- Sedentary
- High cholesterol
- Obstructive sleep apnea
- Smoking

Once diagnosed, all patients should undergo changes in lifestyle before starting drug therapy. The main ones are:

- Weight reduction
- Start exercising
- Quit smoking
- Reduce the consumption of alcohol
- Reduce salt intake
- Reduce consumption of saturated fat
- Increase consumption of fruits and vegetables

Those patients who have come to the doctor with high blood pressure and signs of target organ damage, should begin drug treatment as soon as it indicates long-standing hypertension.

Only patients with signs of target organ damage, chronic renal failure, diabetes or heart disease should start drug treatment immediately. Obviously, changes in lifestyle are also needed in this group.

The problem is that most patients can not accept changes in lifestyle and end up taking medication to control blood pressure.

The pressure reduction with these life style changes is usually small and hardly a person with very high blood pressure (> 160 x 100 mm Hg) can control it without the help of drugs.

Treatment of hypertension

Numerous drugs are used to treat hypertension, the major options are:

1.) Thiazide diuretics.

Ex: Hydrochlorothiazide, Indapamide and Chlorthalidone

Cheap drug with great results. If it is not the first choice, it should be the second.

They are excellent antihypertensive drugs for black people and elderly.

Very high doses can interfere with glucose control in diabetics. Diuretics increase the uric acid and should be avoided in those with gout.

The Lasix (furosemide) is a diuretic and another class is not indicated as treatment for hypertension, except in patients with heart failure or chronic renal failure.

2.) ACE inhibitors and angiotensin receptor blockers

Ex: Captopril, enalapril, ramipril, lisinopril, losartan, candesartan, olmesartan

Also an excellent drug to control blood pressure. Indicated mainly for young people or patients with cardiovascular disease, chronic renal failure and proteinuria.

Not a very good choice for black people since it seems not to work so well. Another problem is that it can raise the blood potassium and cause allergies in some patients.

3.) Inhibitors, calcium channel

Ex: Nifedipine and Amlodipine

Best choice for black peoples and very good for the elderly. However, it can be used in any group of patients.

Some people present edema (swelling) in the lower limbs as a side effect.

4.) Beta-blockers

Ex: Propranolol, Atenolol, Carvediolo, metoprolol, bisoprolol

Inferior than the previous 3, but should be first choice for patients with cardiovascular disease, cardiac arrhythmias, migraine headaches, hyperthyroidism and anxious people with trembling hands.

Should not be used for asthmatics and people with heart rate below 60 per minute.

More than 90% of hypertensive patients have to take 1 or more of the remedies described above. to control its blood pressure.

Patients with benign prostatic hyperplasia should use another class called alpha blockers such as Prazosin and Doxazosin. These �2nd line� drugs should not be prescribed in other groups.

Some people have hypertension difficult to control and, sometimes, need 4, 5 or 6 antihypertensive drugs.

In this case there are alternatives such as hydralazine, methyldopa, clonidine and minoxidil, potent drugs, used in severe cases.