i bc27f85be50b71b1 (194 page)

in children who are between the ages of

6 and 15 years. Rheumaric fever is characterized by nonsuppurarive

inflammarory Ie ions occurring in any or all of the connective tissues

of the heart, joints, subcutaneous tissues, and central nervous system.

An altered immune reaction to the infection is suspected as the cause

of resultant damage to these areas, but the definitive etiology is

unknown. Rheumatic heart disease is the term used to describe the

resultant damage to the heart from the inflammatory process of rheumatic fever.12.19.33.J4

Cardiac manifestations can include pericarditis, myocarditis, leftsided endocarditis, and valvular stenosis and insufficiency with resulrant organic heart murmurs, as well as congestive heart failure. If not managed properly, all of rhese condirions can lead to significant morbidity or dearh. 1l,I9,JJ

Management of rheumatic fever follows rhe treatment for streptococcal infection. The secondary complications mentioned previously are then managed specifically. The gcneral intervention scheme may

include rhe following 1l.19.":

• Prcvention of streptococcal infection

• Anti-infective agents

• Antipyretic agents

• Corticosteroids

• Bed rest

• i.v. Ouids (as needed)

Neurologic Infections

Poliomyelitis

Poliomyelitis is an acute systemic viral disease that affects the central nervous system. Polio viruses are a type of enterovirus that mulriply in rhe oropharynx and inrestinal rracr. There are rhree

serotypes of poliovirus, types 1, 2, and 3 respectively, with type 1

being the mOSt common cause of polio epidemics in certain areas

of rhe world. 1l,J5

626 AClITE CARE HANDBOOK t'OR I�IIYSICAL lllERAPISTS

Poliomyelitis is usually transmitted directly by the fecal-oral route

from person to person but can also be transmitted indirectly by consumption of contaminated water sources.3S

Clinical presentation can range from subclinical infection, to non febrile illness (24-36 hours), to aseptic meningitis, to paralysis (after 4

days), and, possibly, to death. Polio can also be classified as spinal, bulbar, or spinobulbar disease, depending on the areas of the nervous system that are affected. If paralysis does occur, it is generally associated with fever and muscle pain. The paralysis is usually asymmetric and

involves muscles of respiration, swallowing, and the lower extremities.

Paralysis can resolve completely, have residual deficits, or be fatal. 12,J5

Management of poliomyelitis primarily consists of prevention with

inactivated poliovirus vaccine (IPV) given as four doses to children from

the ages of 2--{) years of age.J5 [f a patient does develop active poliomyelitis, then other management strategies may include the following12;

• Analgesics and antipyretics

• Enteric precautions for 7 days after the onset of the disease

• Supplemental oxygen, assisted ventilation, or both

• Bronchopulmonary hygiene

• i.v. fluids and nasogastric feedings

• Bed rest with contracture prevention with positioning and range

of motion

Postpoliomyelitis SY1ldrome

Postpoliomyelitis syndrome occurs 30-40 years after an episode of

childhood paralytic poliomyelitis. It results in muscle fatigue, pain,

and decreased endurance. Muscle atrophy and fasciculations may also

be present. Patients who are older or critically ill, who have had a previous diagnosis of paralytic poliomyelitis, and who are female are at greater risk for development of this syndrome.Js.J•

Meningitis

Meningitis is an inflammation of the meninges, which cover the brain

and spinal cord, that results from acute infection by bacteria, viruses,

fungi, or parasitic worms, or by chemical irritation. The route of

transmission is primarily inhalation of infected airborne mucous

INFECfJOUS DISEASES

627

droplets released by infected individuals or through the bloodstream

via open wounds or invasive procedures.J7•J8

The more common types of meningitis are (1) meningococcal meningitis, which is bacterial in origin and occurs in epidemic form; (2) Haemophil"s meningitis, which is the mOSt common form of bacterial meningitis; (3) pneumococcal meningitis, which occurs as an extension of

a primary bacterial upper respiratOry tract infection; and (4) viral (aseptic

or serous) meningitis, which is generally benign and self-limiting.

Bacterial meningitis is more severe than viral meningitis and affects

the pia mater, arachnoid and subarachnoid space, ventricular system,

and the cerebrospinal fluid. The primary complications of bacterial

meningitis include an increase in intracranial pressure, resulting in

hydrocephalus. This process frequently results in severe headache and

nuchal rigidiry (resistance to neck flexion). Other complications of

meningitis include arthritis, myocarditis, pericarditis, neuromotor and

intellectual deficits, and blindness and deafness from cranial nerve

(III, IV, VI, VII, or VIII) dysfunction.37•J8

Management of any form of meningitis may consist of the

following 12.37:

• Anti-infective agents or immunologic agents lampicillin, penicillin,

cephalosporins (ceftriaxone [Rocephin] or cefotaxime [Claforan])]

• Analgesics

• Mechanical ventilation (as needed)

• Blood pressure maintenance with I. v. fluid and vasopressors

(e.g., dopamine)

• Intracranial pressure control

E",;ephalitis

Ellcephalitis is an inflammation of the tissues of the brain and spinal

cord, commonly resulting from viral or amebic infection. Types of

encephalitis include infectious viral encephalitis, mosquito-borne viral

encephalitis, and amebic meningoencephalitis.

Infectious viral encephalitis is transmitted by direct contact of

droplets from respiratOry passages or other infected excretions and is

most commonly associated with the herpes simplex type 1 virus. Viral

encephalitis can also occur as a complication of systemic viral infections, such as poliomyelitis, rabies, mononucleosis, measles, mumps, rubella, and chickenpox. Manifestations of viral encephalitis can be

628

AClITE CARE HANDBOOK FOR PHYSICAL TIIERAPISTS

mild to severe, with herpes simplex virus encephalitis having the highest mortality rate among all types of encephalitides.12.37.J8

Mosquito-bome viral encephalitis is transmitted by infectious mosquito bites and cannOt be transmirred from person to person. The incidence of this type of encephalitis can be epidemic in nature and

typically varies according to geographic regions and seasons.12.37.38

Amebic meningoencephalitis is transmirred in water and can enter

a person's nasal passages while he or she is swimming. Amebic meningoencephalitis cannOt be rransmitted from person to person.

General clinical presentation of encephalitis may include any of the

following 12.37.38,

• Fever

• Signs of meningeal Irntation from increased intracranial pressure (e.g., severe frontal headache, nausea, vomiting, dizziness, nuchal rigidity)

• Altered level of consciousness, irritability, bizarre behaviors (if

the temporal lobe is involved)

• SeiZllres (mostly in infants)

• Apha ia

• Focal neurologic signs

• Weakness

• Altered deep tendon reAexes

• Ataxia, spasticity, tremors, or flaccidity

• Hyperthermia

• Alteration in antidiuretic hormone secretion