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Tropical bacterial infections often are associated with renal complica- tions that vary according to the causative organism order eulexin 250 mg overnight delivery, severity of infection order eulexin 250mg overnight delivery, and individual susceptibility purchase eulexin 250mg on line. The principal acute infections reported to affect the kidneys are salmonellosis, shigellosis, leptospirosis, melioidosis, C H A P T ER cholera, tetanus, scrub typhus, and diphtheria [8–16]. Renal involvement in mycobacterial infections such as tuberculosis and leprosy usually pur- sues a subacute or chronic course [17–19]. The respective renal pathologies include cosis, which occurs in underdeveloped tropical regions, partic- glomerular, microvascular, and tubulointerstitial lesions. Also described is The pathogenesis of renal complications in tropical bacterial ochratoxin, a fungal toxin often incriminated in the pathogen- infections is multifactorial. The principal factors are direct tis- esis of Balkan nephropathy. Ochratoxin also contributes to pro- sue invasion by the causative organisms and remote cellular and gressive interstitial nephropathy in Africa. The rela- Three ways exist by which parasitic infections cause renal tive significance of the different pathogenetic mechanisms disease: 1) direct physical invasion of the kidneys or urinary varies with the causative organism. Infective Tropical Nephropathies Bacterial Infections CLINICAL M ANIFESTATIONS OF TROPICAL BACTERIAL NEPHROPATHIES Disease Abnormal sediment Proteinuria ARF CRF HUS Hemolysis DIC Jaundice Commonly associated features Salmonellosis +++ ++++ + - + + + + Gastrointestinal Shigellosis + - ++* + + + Neurologic† Leptospirosis ++++ ++++ ++++ - + + + ++++ Hemorrhagic tendency Polyuria‡ Melioidosis +++++ + ++ - Hyponatremia§ Cholera + - Hypokalemia, acidosis Tetanus + ++++ +++ - Sympathetic overflow Scrub typhus + ++ + - + + Diphtheria + + + - Myocarditis, polyneuritis Tuberculosis ++ +/+++ + Retroperitoneal nodes Leprosy ++ +++ + + Lepromas *Associated with Shigella serotype I endotoxin. ARF— acute renal failure; CRF— chronic renal failure; DIC— disseminated intravascular coagulation; HUS— hemolytic uremic syndrome; +— <10%; ++— 10%–24%; +++— 25%–49%; ++++— 50%–80%; +++++— >80%. FIGURE 6-1 Clinical m anifestations of tropical bacterial nephropathies. N ote the wide spectrum of clinical m anifestations that m ay ultim ately reflect on the kidneys [33–35]. AIN— acute interstitial nephritis; ATN— acute tubular necrosis; CGN— crescentic glomerulonephritis; EXGN— exudative glomeru- lonephritis; MCGN— mesangiocapillary glomerulonephritis; MN— membranous glomerulopathy; NG— necrotizing glomerulitis; +— <10%; ++— 10%–24%; +++— 25%–50%. FIGURE 6-2 Spectrum of renal pathology in tropical bacterial infections [36–38]. A B FIGURE 6-3 Glom erular lesions associated with tropical bacterial patient with shigellosis. A, Sim ple proliferative glom erulonephritis in a patient with salm onellosis. D, M em branous nephropathy associated with leprosy. A, Acute tubular necrosis with erythrocyte aggregates in the tubular lum ina in a patient with leptospiro- sis. H ere leptospires (arrow) in the Renal tuberculosis. The subsequent evolution of these pathways m ay lead to different form s of renal injury. The asterisk indicates that the role of hem olysis is augm ented in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. ATN — acute tubular necrosis; DIC— dissem inated intravascular coagulation; IL— interleukin; N O — nitric oxide; RO M — reactive oxygen m olecules; TN F- — tum or necrosis factor-. FIGURE 6-11 Pathogenetic m echanism s in acute tubular necrosis associated with bacterial infections. N ote the m ultiplicity of factors depending on the bacterial species and their host targets. Viral Infections FIGURE 6-12 90 Clinical m anifestations of renal involvem ent in dengue hem orrhag- 80 ic fever. N ote that proteinuria and abnorm al urinary sedim ent are 70 the m ost com m on m anifestations. Also note the high incidence of 60 hyponatrem ia, like with m any other tropical infections [40,41]. A, M esangial proliferative glom erulonephritis, which usually is associ- ated with deposits of im m unoglobulins G and M and com plem ent 3. N ote the high prevalence of schistosom al, m alarial, filarial, and echinococcal renal com plications in Africa; Echinococcosis S. A, A sheet of Schistosom a haem atobium ova in tissues. Shown is a delayed hypersensi- tivity reaction of the host to soluble oval antigens released from the ova through m icropores in their shells. The granulom a is com posed of m ononuclear cells, a few neutrophils, eosinophils, and fibroblasts, surrounding a distorted egg. B, Bilharzial subm ucous m ass covered by pseudotubercles. The ureters are dilat- ed, with a clear stric- ture at the lower end of the right ureter. Also seen in this patient are bilateral hydroureters with submucous cystic lesions (bilharzial ureteritis cystica). The kidneys show consid- erable scarring, with the right kidney also showing chronic back pressure changes. These erythrocyte necrosis knobs contain novel proteins, m ainly Plasm odium falciparum erythrocyte m em - brane protein (PfEM P), histidine-rich pro- FIGURE 6-21 tein 1, and histidine-rich protein 2, that are The pathogenesis of falciparum m alarial renal com plications. N ote the infection triggers synthesized under the influence of the DN A two initially independent pathways: red cell parasitization and m onocyte activation. These proteins con- subsequently interact, as the infected red cells express abnorm al proteins that induce an stitute the sticky points (arrows) by which im m une reaction by their own right, in addition to providing sticky points (knobs) for parasitized erythrocytes aggregate and clum ping and adherence to platelets and capillary endothelium. TN F- released from the adhere to blood platelets and endothelial activated m onocytes shares in the endothelial activation. EN — electron m icrophoto- interact, a variety of renal com plications develop, including acute tubular necrosis, acute graph. B— B-lym phocyte; CD8— cytotoxic T cell; CIC— circulating im m une com plexes; TH — T-helper cells (1 and 2); TN F- — tum or necrosis factor-.

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Less well appreciated is that nicotine the poorest access to health care cheap 250 mg eulexin with visa. Thus buy 250 mg eulexin with amex, from a world view eulexin 250 mg fast delivery, itself is a neuroteratogen (89). Nicotine given to rats during cost of therapeutics and access become important considera- gestation or adolescence at levels assumed to be consistent tions. Prevention is obviously an important strategy, but with those in human smokers alters gene expression and strategies to prevent tobacco addiction must deal with a produces long-lasting central nervous system cellular dam- politically powerful and wealthy multinational industry pro- age, by reducing cell number and impairing synaptic activity moting use of tobacco (64). The tobacco industry in the and cell signaling (62). Developing brain cells appear partic- United States alone spent 6 billion dollars in 1998 to market ularly vulnerable. In adult rats, similar exposure stimulates cigarettes, about 18 million dollars each day. More is spent nicotinic cholinergic receptors without lasting cellular promoting tobacco use elsewhere in the world. Individual or group behavioral treatments appear Contemporaneous reviews of tobacco addiction thera- almost equally effective. Intensive treatment programs are peutics (59,70–73) and an extensive report on tobacco ad- effective in assisting even very dependent smokers to stop diction pharmacology and therapeutics from the Royal Col- for a few months. However, as with other addictions, relapse lege of Physicians (49) offered similar conclusions. Initial quitting rates of 50% to 60% summary review from the Cochrane Tobacco Addiction Re- at 1 month typically decrease to 20% to 30% at 1 year. Details of the 20 None has proven clearly effective. Most tobacco addicts re- systematic reviews are available on the Internet in the Coch- peat the quitting process on average every 3. The reviews used a similar strategy and three or four times before finally stopping forever (66). In reviewed much the same literature on tobacco addiction that respect, stopping smoking is similar to overcoming ad- therapeutics as did the Public Health Service review. Tobacco addiction The Cochrane reviews considered the results from ran- treatment programs are cost-effective. Average treatment domized controlled trials having at least 6 months of follow- costs per year of life saved are $1,000 to $2,000 per year up (91). Sustained abstinence or point prevalence quit rates for brief counseling alone and $2,000 to $4,000 per year were used in the metaanalysis as necessary. Simple advice of life saved with more intensive counseling and pharmaco- from physicians presented during routine care was studied therapy to aid in smoking cessation (34,67). Smoking cessa- in 31 trials that included 26,000 smokers in a variety of tion treatments are less costly per year of life saved than are clinical settings. Brief advice increased quit rate more than generally accepted therapies for hypertension, hypercholes- no advice (odds ratio, 1. Individual counseling was better than brief advice or usual care. Group therapy was more effective than self- Therapeutics: Clinical Guidelines help materials alone but not consistently better than inter- ventions with more personal contact. Self-help informa- Guidelines for treating tobacco dependence were published tional material and printed descriptions of behavioral strate- in 2000 by the United States Public Health Service (2,13). The detailed report resulted from critical review of approxi- mately 6,000 peer-reviewed articles on tobacco addiction therapeutics and 50 metaanalyses based on that literature Nicotine Replacement Therapeutics (69). NRT decreases the discomfort of nicotine withdrawal. The The major general conclusions were as follows: relatively stable brain nicotine levels resulting from NRT 1. Tobacco dependence is a chronic condition warranting should facilitate a desensitized state for some nicotinic cho- repeated treatment until abstinence is achieved. All are more desensitized than others, both nicotine agonistic tobacco users should be offered treatment. Clinicians and health care systems must institutionalize NRT. In a nicotine-induced desensitized state, norepineph- consistent identification, documentation, and treatment rine release normally stimulated by endogenous acetylcho- of every tobacco user at every visit. Every normally stimulated by endogenous acetylcholine could be tobacco user should be offered at least brief treatment. There is a strong relationship between the intensity of mood states in itself could be rewarding. In addition, some tobacco dependence counseling and effectiveness. Three types of counseling are especially effective: practi- ing cessation lapses is likely during NRT. However, the cal counseling, social support as a part of treatment, and mechanisms of NRT still remain uncertain because the in- social support outside of treatment. Five pharmacotherapies for tobacco dependence are ef- for ultimately stopping smoking (3). Even though with- fective: nicotine gum, nicotine inhaler, nicotine nasal drawal symptoms can be diminished by NRT, other mecha- spray, nicotine patch, and bupropion. At least one of nisms, learning coping skills, and replacing some of the these medications should be prescribed in the absence positive effects of nicotine are important as well.