- Prednisolone 40-80 mg/day tapering slowly over several months. Iritis - Atropin

reactions - Prednisolone 40-80 mg/day tapering slowly over several months. Iritis - Atropine 1 % drop plus Hydrocortisone 1 % drops 4-hourly, plus prednisolone 10-20 mg ay p. o. (ii) Type 2 reactions - Thalidomide 100-400 mg daily (contraindicate in premenopausal women), or Clofazimine 300 mg/day tapering slowly, or Prednisolone 20-40 mg/day tapering over several weeks. C. Surgical treatment - (a) Excision of small lesions Large nodules touched with strong carbolic or nitric acid. Removal of necrosed bones and splitting of nerve sheath if a nerve is constricted by dense fibrous tissue. (b) For persistent localized severe nerve trunk pain, infiltration of the thickened nerve sheath or the nerve itself with 10 ml. 1 % procaine, or with the latter solution to which 25 mg of hydrocortisone and 1,500 units hyaluronidase have en added.. The injection may be repeated..(c) Reconstructive surgery is required for paralysed fingers, foot-drop, and hammer toe, and plastic surgery can correct facial disfigurement caused by loss of eyebrows, facial palsy, saddle-nose deformity, ectropion, pendulous ear lobes. PREVENTION - Child contacts may be given BCG vaccination, especially infants born in leprous families Children who have been in close contact with lepromatous leprosy can be given prophylactic dapsone for a minimum of three years. Now that quantities of M. leprae are available from experimentally infected armadillos, a specific vaccine becomes a possibility. 9. RICKETTSIAL DISEASES Etiology and Epidemiology - Organisms - Small bacteria varying in size from coccoidal to bacillary. They are morphologically indistinguishable from each other, contain both RNA and DNA and are Gram-negative. Transmission - is by arthropods (tics, mites, lice and fleas). Direct man-to-man spread of infection does not occur naturally. Humans become infected when they move into an environment inhabited by infected vectors, or when ecological conditions permit large number of vectors to move into man's environment. The clinical syndrome results from disseminated focal perivasculitis and is similar in all ricketssial diseases, though it varies in severity. MAJOR RICKETTSIAL DISEASES OF MAN - 1. Typhus fever - 1. LOUSE-BORNE OR EPIDEMIC TYPHUS -Caused by R. Prowazeki and transmitted from man to man by human body louse. Incubation period - 10-14 days. (a) Stage of invasion - Abrupt onset with rigors and fever, severe headache, muscular pains and conjunctival injection. Active delirium, insomnia common, severe attack may commence with vomiting, rigor or convulsion. Temperature is high at onset, rises steadily to maximum on 5th day. (b) Stage of eruption and nervous excitement - (i) Rash - usually on 5th day. Pink macules varying in size and shape, disappearing on pressure. Generalised but face rarely involved. In a day or two lesions become dull red and finally slate blue or grey before disappearing. Petechiae may occur. Following eruption of macules, paler subcuticular lesions appear between the macules - subcuticular mottling or mulberry rash. (ii) Temperature - high till the 6th day. (iii) Delirium -replaces headache and stupor. Mostly at night. (iv) Spleen may be palpable. (c) Stage of prostration - Patient appears exhausted and stuporose, this may progress to delirium or coma. Hypotension may result from myocarditis and peripheral vasodilatation .Features of grave prognostic significance include - progressive fall of B. P , gangrene of fingers or toes, pressure areas and genitalia, urinary and faecal incontinence, renal failure and secondary infection. (d) Stage of defervescence- In favourable cases about the 12th or 14th day striking improvement occurs. Patient becomes quieter. Fever becomes remittent and drops to normal in a few days. Complications - (a) Bronchopneumonia. (ii) Myocarditis. (iii) Thromboembolic complications. (iv) Peripheral failure. (v) Suppurative parotitis. (vi) Gangrene of areas of skin. 2. BRILL-ZINSSER DISEASE - is a recrudescent form of epidemic typhus. Intense frontal headache and low B. P. are prominent features. Scrub typhus-caused by R. tsutugamushi and transmitted by larval mites. Eschar at site of mite feeding. Lymph nodes draining the eschar swollen and tender with generalised lymphadenopathy, fever, chills, headache, malaise and orbital pain. Maculopapular rash in about 50% may appear between 3rd and 7th day. Lymphocytosis in blood (large lymphocytes). Convalascence prolonged. Diag. - (a) Serology. Detection of antibodies by microimmunofluorescence (MIF). A tit re of 1: 128 in diagnostic. (b) Weil Felix reaction- Louse and flea or tick borne typhus agglutinate with strain OX-19 and OX-2, scrub typhus with OX-K alone. Tr. - Doxycycline 200 mg/day for 10 days. II. Spotted fevers-ROCKY MOUNTAIN SPOTTED FEVER - is the most severe form. Caused by R. ricketsii and carried by ticks. Abrupt onset of fever with chills, severe headache, photophobia, prostration and muscle and joint pains. Temperature 40°-41 °C with irregular morning remissions. Rash on 3rd or 4th day, maculopapular, first on extremities then spreading to the trunk, the rash becoming petechial. In severe cases rash becomes confluent, deep red or purple and may necrose. CNS manifestations include restlessness, confusion and delirium. In severe cases coma and peripheral vascular collapse precede death.