Rabies: scary consequences
Dr J.L. Agarwal

Everyone is afraid of rabies. It is also called hydrophobia because patients have intense fear of water and become incapable of drinking though extremely thirsty. Disease is transmitted by the bites of rabid animals. About 95-97 per cent cases of rabies in humans are due to a dog’s bite. It can also occur by the bites of other infected animals like cats, jackals, mongooses, monkeys, bears, wolves and hyena. Sometimes even rats get infected by rabies.

About three million people get injections of the rabies vaccine after being bitten by dogs and other animals each year.

Rabies is primarily a disease of animals. It is prevalent in wild animals and stray dogs. As viruses are present in the saliva of infected animals, when a rabid dog or some other animal bites or licks the man, then viruses enter through the wound, multiply in the connective tissues and muscles. These viruses enter the nerves and travel along it to reach the brain and further multiply here. From the brain, viruses spread via the nerves to various organs. They also reach salivary glands.

The disease appear any time from 10 days to three years after the bite — the usual duration is one to three months. The duration is shorter in children than in adults.

Viruses are present in the saliva and other secretions of rabies patients. Proper precautions should be observed by the caretakers of these patients.

Symptoms

Rabies is a fatal disease. Once symptoms appear, death is almost certain. The disease in humans occurs in stages. Patients develop pain in the nerves and muscles along with the twitching of muscles. They develop fever, headache, malaise, loss of appetite, etc. Patients become anxious, agitated, irritable. Most become hyperactive and furious and develop a bizarre behaviour. They can have seizure attacks by light, sound, touch, or even spontaneously. If they try to drink water, they develop painful spasm of larynx and have a dread for water. Even the sight and sound of water can cause spasm. Death usually occurs due to respiratory arrest during convulsions.

Some patients develop paralysis; they remain mentally alert till the last moment.

The patients who somehow survive go into a coma and then die. All patients die within one-three weeks without intensive supportive care.

Preventing rabies

Rabies is a deadly disease. Preventive means should be adopted as soon as possible following a dog bites. Once the viruses reach the nerve tissue, taking a vaccine and other treatment become ineffective.

Care of wound: After the animal’s bites, clean the wound with soap and water vigorously for about 10 minutes followed by the flushing of wound with water. Then the wound should be irrigated with 1 per cent solution of Benzalkonium chloride, which can kill rabies viruses. Patients should be given the anti-tetanus vaccine and sutable antibiotics. Dead tissue or crushed tissue around the wound should be removed the wound should not be sutured.

Immunisation: This is the only way to protect your self from rabies after a rabid animal bites. Previously, a nerve tissue vaccine was available, which was prepared from the goat brain. These injections were given in the abdomen, which were very painful. They were of low potency. Now tissue culture vaccines are available. They are more potent, safer, almost painless, but expensive.

When to get anti-rabies vaccine?

l If the animal concerned show, signs of rabies or dies within 10 days of bites.

l If the animal cannot be identified or traced.

l Unprovoked bite by animals.

l The biting animal is found positive for rabies in laboratory tests after being killed or when it dies on its own.

l All bites by wild animals.

Advise to the patients receiving anti-rabies vaccine

l They should not drink alcohol for at least one month.

l They should not indulge in undue physical and mental exertion.

l Late nights should be avoided.

l Steroids and other immunosuppressant drugs should not be consumed.

l The full course of vaccine should be taken as rabies can develop after incomplete immunisation.

The writer is Professor and Head, SIMS, Hapur (Ghaziabad), UP.

Vitamin A makes breastfeeding with HIV more risky

Washington: Scientists have revealed that vitamin A and beta-carotene supplements are unsafe for HIV-positive women who breastfeed because they may boost the excretion of HIV in breast milk, thereby increasing the chances of transmitting the infection to the child.

Epidemiologist Eduardo Villamor of the University of Michigan School of Public Health says transmission of HIV through breastfeeding happens because breast milk carries viral particles that the baby ingests.

Supplementing HIV-positive women with vitamin A and beta-carotene appears to increase the amount of the virus in milk.

This may be partly because the same nutrients raise the risk of developing subclinical mastitis, an inflammatory condition, which causes blood plasma to leak into the mammary gland and viral particles to then leak into the milk, he says.

The results are significant because they provide biological explanations for a previous report that supplementation with these nutrients increased chances of mother-to-child HIV transmission.

“So there are now strong arguments to consider the implications of supplementation to pregnant or lactating women who are HIV-positive. It does not look like it’s a safe intervention for them,” said Villamor.

Mother-to-child HIV transmission is a huge problem in developing countries where HIV is prevalent, Villamor said. In 2008 alone, there were 430,000 new infections and more than 95 per cent of those resulted from mother-to-child transmission. Most were in sub-Saharan Africa.

In one of the studies, 1,078 HIV-infected women were divided into four groups. The test groups received either 5,000 IU of vitamin A and 30 mg of beta-carotene everyday during gestation and the lactation period, or a control regimen.

The dose for beta-carotene was higher than the amount usually provided by the diet, according to Villamor. Smaller doses might not have the same effect.

Villamor said tests trying to separate the effects of each nutrient showed that beta-carotene seemed to increase the amount of HIV in breast milk independent of vitamin A, but an effect of vitamin A alone cannot be ruled out.

The findings are potentially controversial because vitamin A is an important supplement for postpartum women in countries where HIV infection is highly prevalent, but supplementation programs may not take into account a woman’s HIV status.

“The takeaway is that daily supplementation of HIV-infected pregnant or lactating women with vitamin A and beta-carotene at the doses tested is probably not safe and efforts need to be strengthened on preventing mother-to-child transmission through other interventions such as anti-retroviral regimens,” Villamor said. — ANI

How to handle elderly patients with acute abdominal pain
Dr J. D Wig

Acute abdomen problems in the elderly pose a difficult challenge for clinicians. Almost 50 per cent of these patients presenting with acute abdominal pain need hospitalisation. Of these, 30 to 40 per cent eventually require surgery for their underlying condition. Approximately 40 per cent of these patients are misdiagnosed initially.

The elderly are often viewed as high-risk patients, and elective surgery may not be performed. The result is that a potentially treatable disease process may develop into an acute catastrophic event.

Many diseases present and evolve differently in elderly patients. An aged immune system has a decreased ability to react to common disease processes. Elderly patients are less likely to have fever. Their pain is often much less severe than would be expected for a particular disease and leads to a delay in presentation. Pre-existing conditions and certain medications have the potential to interfere with the physical examination. A delay in presentation to the hospital may also be due to diminished perceptions, or diminished ability to express the symptoms effectively.

Early and correct diagnosis is critical and significantly influences the outcome. Atypical presentation is the rule. The physical examination is less accurate owing to an abnormal inflammatory response. The elderly patient with abdominal pain may have a potentially lethal process despite a non-specific examination and normal laboratory studies.

Laboratory studies are not very helpful in elderly patients and may be normal even in a seriously ill patient. The widely used abdominal ultrasound examination and computed tomography help in making a definitive diagnosis of acute abdomen. The elderly patient with undiagnosed abdominal pain must be investigated for malignancy. Change in bowel habits, weight loss, anorexia and rectal bleeding indicate the possibility of bowel cancer.

The most common causes of abdominal pain requiring surgical correction are complicated gallstone disease, acute appendicitis, obstructed hernias, intestinal obstruction, intestinal perforation, cancer and vascular conditions. One must consider intra-abdominal cancer and vascular lesions as a cause of abdominal pain in an older patient. Pain out of proportion to the physical findings points to bowel ischemia. Acute appendicitis in older patients is often poorly diagnosed at the outset. This can cause a higher complication rate compared to young patients.

Emergency hernia surgery carries a high mortality. Gallstone disease is a common cause of abdominal pain. The patient may be actually ill and may have empyema gallbladder, gangrenous cholecystitis, or a free perforation. Intestinal obstruction is a major health problem in older patients. The incidence of peptic ulcer is increasing in the elderly owing in part to the increasing use of aspirin and anti-inflammatory drugs. The complications include perforation and massive bleeding. Mortality in patients with complications of peptic ulcer is extremely high.

Treatment plans are individualised depending on the underlying cause. Treatment generally involves a multifaced plan that addresses the cause, minimises the discomfort, and decreases the risk of developing serious complications. Sound judgement and clinical skills are of utmost importance. Surgical decisions must never be based on the age of the patient.

In patients with unclear diagnosis, a follow-up appointment within 12 to 24 hours must be arranged. Family members must be instructed to revisit immediately for any worsening of pain.

The only way to improve the results is to manage elderly patients electively. Patients with hernias or gallstones should have a planned operation. Change in bowel habits should be studied adequately.

Acute abdomen in the elderly is a difficult and life-threatening disease that must be aggressively investigated and managed. Clinical and laboratory data are less useful. Assume that an elderly patient has a surgical cause of pain unless proved otherwise. Acute abdominal pain complaints often require hospital admission. Older patients with acute abdominal pain need to be evaluated as carefully as those presenting with acute chest pain.

The writer is a former Professor and Head, Department of General Surgery, PGI, Chandigarh.