Thursday, April 30, 2009

Dengue! A Painful Mosquitoe Bite

What is dengue fever?

Dengue fever is a disease caused by a family of viruses that are transmitted by mosquitoes. It is an acute illness of sudden onset that usually follows a benign course with headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue.

Dengue (pronounced DENG-gay) strikes people with low levels of immunity. Because it is caused by one of four serotypes of virus, it is possible to get dengue fever multiple times. However, an attack of dengue produces immunity for a lifetime to that particular serotype to which the patient was exposed.

Dengue goes by other names, including "breakbone" or "dandy fever." Victims of dengue often have contortions due to the intense joint and muscle pain, hence the name breakbone fever. Slaves in the West Indies who contracted dengue were said to have dandy fever because of their postures and gait.

Dengue hemorrhagic fever is a more severe form of the viral illness. Manifestations include headache, fever, rash, and evidence of hemorrhage in the body. Petechiae (small red or purple blisters under the skin), bleeding in the nose or gums, black stools, or easy bruising are all possible signs of hemorrhage. This form of dengue fever can be life-threatening or even fatal.


What areas are at high risk for contracting dengue fever?

Dengue is prevalent throughout the tropics and subtropics. Outbreaks have occurred in the Caribbean, including Puerto Rico, the U.S. Virgin Islands, Cuba, and Central America. Cases have also been imported via tourists returning from areas with widespread dengue, including Tahiti, the South Pacific, Southeast Asia, the West Indies, India, and the Middle East.

Dengue fever is common and may be increasing in Southeast Asia. Thailand, Vietnam, Singapore, and Malaysia have all reported an increase in cases. According to the World Health Organization, there are an estimated 50 million cases of dengue fever with 500,000 cases of dengue hemorrhagic fever requiring hospitalization each year. Nearly 40% of the world's population lives in an area endemic with dengue.

How is dengue contracted?

The virus is contracted from the bite of a striped Aedes aegypti mosquito that has previously bitten an infected person. The mosquito flourishes during rainy seasons but can breed in water-filled flower pots, plastic bags, and cans year-round. One mosquito bite can inflict the disease.

The virus is not contagious and cannot be spread directly from person to person. There must be a person-to-mosquito-to-another-person pathway.

What are the signs and symptoms of dengue?

After being bitten by a mosquito carrying the virus, the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear. Dengue starts with chills, headache, pain upon moving the eyes, and low backache. Painful aching in the legs and joints occurs during the first hours of illness. The temperature rises quickly as high as 104° F (40° C), with relative low heart rate (bradycardia) and low blood pressure (hypotension). The eyes become reddened. A flushing or pale pink rash comes over the face and then disappears. The glands (lymph nodes) in the neck and groin are often swollen.

Fever and other signs of dengue last for two to four days, followed by rapid drop in temperature (defervescence) with profuse sweating. This precedes a period with normal temperature and a sense of well-being that lasts about a day. A second rapid rise in temperature follows. A characteristic rash appears along with the fever and spreads from the extremities to cover the entire body except the face. The palms and soles may be bright red and swollen.

How is dengue fever treated?

Because dengue is caused by a virus, there is no specific medicine or antibiotic to treat it. For typical dengue, the treatment is purely concerned with relief of the symptoms (symptomatic). Rest and fluid intake for adequate hydration is important. Aspirin and nonsteroidal anti-inflammatory drugs should be avoided. Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia).

What is the outcome with typical dengue?

Typical dengue does not result in death. It is fatal in less than 1% of cases. The acute phase of the illness with fever and myalgias lasts about one to two weeks. Convalescence is accompanied by a feeling of weakness (asthenia), and full recovery often takes several weeks.

What is dengue hemorrhagic fever?

Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect children under 10. It causes abdominal pain, hemorrhage (bleeding), and circulatory collapse (shock). DHF is also called Philippine, Thai, or Southeast Asian hemorrhagic fever and dengue shock syndrome.

DHF starts abruptly with high continuous fever and headache. There are respiratory and intestinal symptoms with sore throat, cough, nausea, vomiting, and abdominal pain. Shock occurs two to six days after the start of symptoms with sudden collapse, cool, clammy extremities (the trunk is often warm), weak pulse, and blueness around the mouth (circumoral cyanosis).

In DHF, there is bleeding with easy bruising, blood spots in the skin (petechiae), spitting up blood (hematemesis), blood in the stool (melena), bleeding gums, and nosebleeds (epistaxis). Pneumonia is common, and inflammation of the heart (myocarditis) may be present.

Patients with DHF must be monitored closely for the first few days since shock may occur or recur precipitously. Cyanotic (bluish) patients are given oxygen. Vascular collapse (shock) requires immediate fluid replacement. Blood transfusions may be needed to control bleeding.

The mortality, or death rate, with DHF is significant. It ranges from 6%-30%. Most deaths occur in children. Infants under a year of age are especially at risk of dying from DHF.

How can dengue fever be prevented?

The transmission of the virus to mosquitoes must be interrupted to prevent the illness. To this end, patients are kept under mosquito netting until the second bout of fever is over and they are no longer contagious.

The prevention of dengue requires control or eradication of the mosquitoes carrying the virus that causes dengue. In nations plagued by dengue fever, people are urged to empty stagnant water from old tires, trash cans, and flower pots. Governmental initiatives to decrease mosquitoes also help to keep the disease in check but have been poorly effective.

Wear long pants and long sleeves. For personal protection, use mosquito repellant sprays that contain DEET when visiting places where dengue is endemic. Limiting exposure to mosquitoes by avoiding standing water and staying indoors two hours after sunrise and before sunset will help. The Aedes aegypti mosquito is a daytime biter with peak periods of biting around sunrise and sunset. It may bite at any time of the day and is often hidden inside homes or other dwellings, especially in urban areas.

There is currently no vaccine available for dengue fever. There is a vaccine undergoing clinical trials, but it is too early to tell if it will be safe or effective.

References:

http://www.phac-aspc.gc.ca/tmp-pmv/2007/dengue070823_e.html

http://www.who.int/tdr/publications/publications/pdf/planning_dengue.pdf

http://www.cdc.gov/ncidod/dvbid/dengue/


The Spanish Lady brought the world chaos

The Influenza Pandemic of 1918


The influenza pandemic of 1918-1919 killed more people than the Great War, known today as World War I (WWI), at somewhere between 20 and 40 million people. It has been cited as the most devastating epidemic in recorded world history. More people died of influenza in a single year than in four-years of the Black Death Bubonic Plague from 1347 to 1351. Known as"Spanish Flu" or "La Grippe" the influenza of 1918-1919 was a global disaster.

In the fall of 1918 the Great War in Europe was winding down and peace was on the horizon. The Americans had joined in the fight, bringing the Allies closer to victory against the Germans. Deep within the trenches these men lived through some of the most brutal conditions of life, which it seemed could not be any worse. Then, in pockets across the globe, something erupted that seemed as benign as the common cold. The influenza of that season, however, was far more than a cold. In the two years that this scourge ravaged the earth, a fifth of the world's population was infected. The flu was most deadly for people ages 20 to 40. This pattern of morbidity was unusual for influenza which is usually a killer of the elderly and young children. It infected 28% of all Americans (Tice). An estimated 675,000 Americans died of influenza during the pandemic, ten times as many as in the world war. Of the U.S. soldiers who died in Europe, half of them fell to the influenza virus and not to the enemy (Deseret News). An estimated 43,000 servicemen mobilized for WWI died of influenza (Crosby). 1918 would go down as unforgettable year of suffering and death and yet of peace. As noted in the Journal of the American Medical Association final edition of 1918:

"The 1918 has gone: a year momentous as the termination of the most cruel war in the annals of the human race; a year which marked, the end at least for a time, of man's destruction of man; unfortunately a year in which developed a most fatal infectious disease causing the death of hundreds of thousands of human beings. Medical science for four and one-half years devoted itself to putting men on the firing line and keeping them there. Now it must turn with its whole might to combating the greatest enemy of all--infectious disease," (12/28/1918).


The effect of the influenza epidemic was so severe that the average life span in the US was depressed by 10 years. The influenza virus had a profound virulence, with a mortality rate at 2.5% compared to the previous influenza epidemics, which were less than 0.1%. The death rate for 15 to 34-year-olds of influenza and pneumonia were 20 times higher in 1918 than in previous years (Taubenberger). People were struck with illness on the street and died rapid deaths. One anectode shared of 1918 was of four women playing bridge together late into the night. Overnight, three of the women died from influenza (Hoagg). Others told stories of people on their way to work suddenly developing the flu and dying within hours (Henig). One physician writes that patients with seemingly ordinary influenza would rapidly "develop the most viscous type of pneumonia that has ever been seen" and later when cyanosis appeared in the patients, "it is simply a struggle for air until they suffocate," (Grist, 1979). Another physician recalls that the influenza patients "died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth," (Starr, 1976). The physicians of the time were helpless against this powerful agent of influenza. In 1918 children would skip rope to the rhyme (Crawford):

I had a little bird,

Its name was Enza.

I opened the window,

And in-flu-enza.

The influenza pandemic circled the globe. Most of humanity felt the effects of this strain of the influenza virus. It spread following the path of its human carriers, along trade routes and shipping lines. Outbreaks swept through North America, Europe, Asia, Africa, Brazil and the South Pacific (Taubenberger). In India the mortality rate was extremely high at around 50 deaths from influenza per 1,000 people (Brown). The Great War, with its mass movements of men in armies and aboard ships, probably aided in its rapid diffusion and attack. The origins of the deadly flu disease were unknown but widely speculated upon. Some of the allies thought of the epidemic as a biological warfare tool of the Germans. Many thought it was a result of the trench warfare, the use of mustard gases and the generated "smoke and fumes" of the war. A national campaign began using the ready rhetoric of war to fight the new enemy of microscopic proportions. A study attempted to reason why the disease had been so devastating in certain localized regions, looking at the climate, the weather and the racial composition of cities. They found humidity to be linked with more severe epidemics as it "fosters the dissemination of the bacteria," (Committee on Atmosphere and Man, 1923). Meanwhile the new sciences of the infectious agents and immunology were racing to come up with a vaccine or therapy to stop the epidemics.


The experiences of people in military camps encountering the influenza pandemic:


An excerpt for the memoirs of a survivor at Camp Funston of the pandemic Survivor

A letter to a fellow physician describing conditions during the influenza epidemic at Camp

Devens


A collection of letters of a soldier stationed in Camp Funston Soldier


The origins of this influenza variant is not precisely known. It is thought to have originated in China in a rare genetic shift of the influenza virus. The recombination of its surface proteins created a virus novel to almost everyone and a loss of herd immunity. Recently the virus has been reconstructed from the tissue of a dead soldier and is now being genetically characterized. The name of Spanish Flu came from the early affliction and large mortalities in Spain (BMJ,10/19/1918) where it allegedly killed 8 million in May (BMJ, 7/13/1918). However, a first wave of influenza appeared early in the spring of 1918 in Kansas and in military camps throughout the US. Few noticed the epidemic in the midst of the war. Wilson had just given his 14 point address. There was virtually no response or acknowledgment to the epidemics in March and April in the military camps. It was unfortunate that no steps were taken to prepare for the usual recrudescence of the virulent influenza strain in the winter. The lack of action was later criticized when the epidemic could not be ignored in the winter of 1918 (BMJ, 1918). These first epidemics at training camps were a sign of what was coming in greater magnitude in the fall and winter of 1918 to the entire world.


The war brought the virus back into the US for the second wave of the epidemic. It first arrived in Boston in September of 1918 through the port busy with war shipments of machinery and supplies. The war also enabled the virus to spread and diffuse. Men across the nation were mobilizing to join the military and the cause. As they came together, they brought the virus with them and to those they contacted. The virus killed almost 200,00 in October of 1918 alone. In November 11 of 1918 the end of the war enabled a resurgence. As people celebrated Armistice Day with parades and large partiess, a complete disaster from the public health standpoint, a rebirth of the epidemic occurred in some cities. The flu that winter was beyond imagination as millions were infected and thousands died. Just as the war had effected the course of influenza, influenza affected the war. Entire fleets were ill with the disease and men on the front were too sick to fight. The flu was devastating to both sides, killing more men than their own weapons could.


With the military patients coming home from the war with battle wounds and mustard gas burns, hospital facilities and staff were taxed to the limit. This created a shortage of physicians, especially in the civilian sector as many had been lost for service with the military. Since the medical practitioners were away with the troops, only the medical students were left to care for the sick. Third and forth year classes were closed and the students assigned jobs as interns or nurses (Starr,1976). One article noted that "depletion has been carried to such an extent that the practitioners are brought very near the breaking point," (BMJ, 11/2/1918). The shortage was further confounded by the added loss of physicians to the epidemic. In the U.S., the Red Cross had to recruit more volunteers to contribute to the new cause at home of fighting the influenza epidemic. To respond with the fullest utilization of nurses, volunteers and medical supplies, the Red Cross created a National Committee on Influenza. It was involved in both military and civilian sectors to mobilize all forces to fight Spanish influenza (Crosby, 1989). In some areas of the US, the nursing shortage was so acute that the Red Cross had to ask local businesses to allow workers to have the day off if they volunteer in the hospitals at night (Deseret News). Emergency hospitals were created to take in the patients from the US and those arriving sick from overseas.


The pandemic affected everyone. With one-quarter of the US and one-fifth of the world infected with the influenza, it was impossible to escape from the illness. Even President Woodrow Wilson suffered from the flu in early 1919 while negotiating the crucial treaty of Versailles to end the World War (Tice). Those who were lucky enough to avoid infection had to deal with the public health ordinances to restrain the spread of the disease. The public health departments distributed gauze masks to be worn in public. Stores could not hold sales, funerals were limited to 15 minutes. Some towns required a signed certificate to enter and railroads would not accept passengers without them. Those who ignored the flu ordinances had to pay steep fines enforced by extra officers (Deseret News). Bodies pilled up as the massive deaths of the epidemic ensued. Besides the lack of health care workers and medical supplies, there was a shortage of coffins, morticians and gravediggers (Knox). The conditions in 1918 were not so far removed from the Black Death in the era of the bubonic plague of the Middle Ages.


In 1918-19 this deadly influenza pandemic erupted during the final stages of World War I. Nations were already attempting to deal with the effects and costs of the war. Propaganda campaigns and war restrictions and rations had been implemented by governments. Nationalism pervaded as people accepted government authority. This allowed the public health departments to easily step in and implement their restrictive measures. The war also gave science greater importance as governments relied on scientists, now armed with the new germ theory and the development of antiseptic surgery, to design vaccines and reduce mortalities of disease and battle wounds. Their new technologies could preserve the men on the front and ultimately save the world. These conditions created by World War I, together with the current social attitudes and ideas, led to the relatively calm response of the public and application of scientific ideas. People allowed for strict measures and loss of freedom during the war as they submitted to the needs of the nation ahead of their personal needs. They had accepted the limitations placed with rationing and drafting. The responses of the public health officials reflected the new allegiance to science and the wartime society. The medical and scientific communities had developed new theories and applied them to prevention, diagnostics and treatment of the influenza patients.


Statistics from the Influenza Epidemic

The massive mortality due to the influenza epidemic in October of 1918 in Kansas

The epidemic of the virulent influenza virus hit Kansas in 1918 leading to the profound effect on mortality. This graph illustrates the severity of the epidemic (US Census Bureau).

Areas of the US where the flu first erupted in the fall of 1918

The port areas saw the earliest cases of influenza which was brought over by boat. The major cities and transportation centers were next on the path. The disease disseminated across the country with the population, with a few focal areas of massive epidemic (Crosby).

The Public Health Response

The responses of the Public Health Departments in Europe and in the United States represented the ideas prevalent in society and in the scientific community. While most of the measures were solidly grounded in the current scientific concepts, they could also be traced back to Medieval and even Classical times of plague and pestilence. The idea of contagion prompting quarantines and isolation dates back to the Justinian Plague. However, epidemiological work by Snow and others in the 19th century did further these notions of contagion and understanding of transmission. Public Health Departments grew out of these advances and the belief in the ability of man to control nature. Sanitation, vaccination programs and other public hygiene efforts in the late 19th century enabled public health officials to gain power and authority. However, the Influenza Pandemic of 1918-19 challenged the public health agencies. The massive morbidities from the common illness of influenza were mysterious and frightening. Many of the measures formerly known to work were ineffective. They were not prepared for an event of this magnitude, lacking the organization and infrastructure and constrained by the war. Yet, the great war provided the rhetoric of nationalism necessary to usher in these authoritative responses and losses of liberty.

Authoritative Measures

The public health authorities in both the United States and Europe took up fundamental measures to control epidemics that dated back to Medieval times of the Bubonic Plague. They aimed to reduce the transmission of the pathogen by preventing contact. They framed their public health orders in scientific ideas of their understanding of how the influenza microbe spread through the air by coughing and sneezing, and their conception of the pathogenesis of influenza. Since they concluded that the pathogen was transmitted through the air, efforts to control contagion were organized to prevent those infected from sharing the same air as the uninfected. Public gatherings and the coming together of people in close quarters was seen as a potential agency for the transmission of the disease. The public health authorities believed that good ventilation and fresh air were "the best of all general measures for prevention, and this implies the avoidance of crowded meetings," (BMJ, 10/19/1918). This translated into the controversial and imperative measure of closing of many public institutions and banning of public gatherings during the time of an epidemic.

The rigidity of these regulations varied immensely with the power of the local health departments and severity of the influenza outbreak. In the United States, the Committee of the American Public Health Association ( APHA) issued measures in a report to limit large gatherings. The committee held that any type of gathering of people, with the mixing of bodies and sharing of breath in crowded rooms, was dangerous. Nonessential meetings were to be prohibited. They determined that saloons, dance halls, and cinemas should be closed and public funerals should be prohibited since they were unnecessary assemblies. Churches were allowed to remain open, but the committee believed that only the minimum services should be conducted and the intimacy reduced. Street cars were thought to be a special menace to society with poor ventilation, crowding and uncleanliness. The committee encouraged the staggering of opening and closing hours in stores and factories to prevent overcrowding and for people to walk to work when possible (JAMA, 12/21/1918). Some of the regulations in Britain were milder, such as limiting music hall performances to less than three consecutive hours and allowing a half-hour for ventilation between shows (BMJ, 11/30/1918). In Switzerland, theaters, cinemas, concerts and shooting matches were all suspended when the epidemic struck, which led to a state of panic (BMJ, 10/19/1918). This variation in response was most likely due to differences in authority of the public health agencies and societal acceptance of their measures as necessary. This necessitated a shared belief in the concept of contagion and some faith in the actions of science to allow them to overcome this plague.

An American school in the 1910s

Prophylaxis

The members of the APHA committee also suggested ways to increase the natural resistance to the illness. They stated that nervous and physical exhaustion should be avoided. People were encouraged to maintain proper rest, to get fresh air and maintain general hygiene. The French report also encouraged avoiding over-fatigue and exposure to the cold (BMJ, 11/2/1918). The Royal College of Physicians shared this opinion saying that the chilling of the body should be prevented by wearing warm clothing out of doors. They also claimed that good nourishment of food and drink was desirable, saying that chill and over-exertion...have evil consequences," (BMJ, 11/16/1918). These methodologies unlike the preventative measures do not appear to have a strong scientific basis. Rather, they reflect common societal ideas about the wellness and the ability to fight infection. Thus to a degree, the medical and public health officials were still using common sense notions to combat this new infectious terror.

One method of preventing infection, however was more scientific, more elaborate and more controversial. This was the gargling and rinsing out of the nasopharynx with antiseptic solution. Physicians held that since the disease was transmitted through the upper respiratory passages, it made sense to disinfected the nose and mouth to prevent infection.

One method was to gargle with warm water mixed with chlorinated soda. A Dr. F. W. Alexander recommended electrolytic disinfection fluid as mouth wash for influenza to be gargled and sniffed up the nose (BMJ, 11/2/1918). Others gargled and sprayed the nasopharynx with a weak solution of carbolic acid and combined it with quinine to prevent infection (BMJ, 11/23/1918). A more serious method of cleansing and disinfecting the nasal spaces and upper air passages was suggested by Dr. James Bach. He advocated a powder of boric acid and sodium bicarbonate. The powder was to be blown into the nose which would then dissolve and by osmotic pressure induce mucus flow to wash the membranes (JAMA, 12/7/1918). This method has a scientific basis but little scientific proof of efficacy. They worked as well as some of the treatments invented to cure influenza which were based on scientific ideas but not scientific results. The APHA members believed that gargling had no value as they cleared out the protective mucus barrier to infection.

The American Public Health Association committee members believed that the best way to prevent infection was through the use of vaccines. Vaccines could prevent or mitigate infection with influenza and the frequently fatal complications of the illness due to the influenza bacillus or strains of streptococci and pneumonococci. They believed that the current vaccines under development should be tested and administered if useful to prevent infection. The committee suggested the use of the experimental vaccines on susceptibles with equal subjects and controls and under proper scientific methodology. However, they acknowledged that the cause of the influenza was unknown and therefore an effective vaccine had no "scientific basis," (JAMA, 12/21/1918). These public health officials shared the perceptions of the scientific and medical community of the influenzal disease and its origins.

The Medical and Scientific Conceptions of Influenza

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Scientific ideas about influenza, the disease and its origins, shaped the public health and medical responses. In 1918 infectious diseases were beginning to be unraveled. Pasteur and Koch had solidified the germ theory of disease through clear experiments clever science. The bacillus responsible for many infections such as tuberculosis and anthrax had been visualized, isolated and identified. Koch's postulates had been developed to clearly link a disease to a specific microbial agent. The petri dish was widely used to grow sterile cultures of bacteria and investigate bacterial flora. Vaccines had been created for bacterial infections and even the unseen rabies virus by serial passage techniques. The immune system was explained by Paul Erhlich and his side-chain theory. Tests of antibodies such as Wasserman and coagulation experiments were becoming commonplace. Science and medicine were on their way to their complete entanglement and fusion as scientific principles and methodologies made their way into clinical practice, diagnostics and therapy.

The Clinical Descriptions of Influenza

Patients with the influenza disease of the epidemic were generally characterized by common complaints associated with the flu. They had body aches, muscle and joint pain, headache, a sore throat and a unproductive cough with occasionally harsh breathing (JAMA, 1/25/1919). The most common sign of infection was the fever, which ranged from 100 to 104 F and lasted for a few days. The onset of the epidemic influenza was peculiarly sudden, as people were struck down with dizziness, weakness and pain while on duty or in the street (BMJ, 7/13/1918). After the disease was established the mucous membranes became reddened with sneezing. In some cases there was a hemorrhage of the mucous membranes of the nose and bloody noses were commonly seen. Vomiting occurred on occasion, and also sometimes diarrhea but more commonly there was constipation (JAMA, 10/3/1918). A few physicians associated psychoses with influenza infection. One article says that "the frequency of mental disturbances accompanying the acute illness in the epidemic has been the subject of frequent comment," (JAMA, 1/25/1919) The danger of an influenza infection was its tendency to progress into the often fatal secondary bacterial infection of pneumonia. In the patients that did not rapidly recover after three or four days of fever, there is an "irregular pyrexia" due to bronchitis or broncopneumonia (BMJ, 7/13/1918). The pneumonia would often appear after a period of normal temperature with a sharp spike and expectorant of bright red blood. The lobes of the lung became speckled with "pneumonic consolidations." The fatal cases developed toxemia and vasomotor depression (JAMA, 10/3/1918). It was this tendency for secondary complications that made this influenza infection so deadly.

A military hospital ward in 1918

In the medical literature characterizing the influenza disease, new diagnostic techniques are frequently used to describe the clinical appearance. The most basic clinical guideline was the temperature, a record of which was kept in a table over time. Also closely monitored was the pulse rate. One clinical account said that "the pulse was remarkably slow," (JAMA, 4/12/1919) while others noted that the pulse rate did not increase as expected. With the pulse, the respiration rate was measured and reported to provide clues of the clinical progression. Patients were also occasionally "roentgenographed" or chest x-rayed, (JAMA, 1/25/1919). The discussion of clinical influenza also often included analysis of the blood. The number of white blood cells were counted for many patients. Leukopenia was commonly associated with influenza. The albumin was also measured, since it was noted that transient albuminuria was frequent in influenza patients. This was done by urine analysis. The Wassermann reaction was another added new test of the blood for antibodies (JAMA, 10/3/1918). These new measurements enabled to physicians to have an image of action and knowledge using scientific instruments. They could record precisely the progress of the influenza infection and perhaps were able to forecast its outcome.

The most novel of these tests were the blood and sputum cultures. Building on the germ theory of disease, the physicians and their associated research scientists attempted to find the culprit for this deadly infection. Physicians would commonly order both blood and sputum cultures of their influenza and pneumonia patients mostly for research and investigative purposes. At the military training camp Camp Lewis during a influenza epidemic, "in all cases of pneumonia...a sputum study, white blood and differential count, blood culture and urine examinations were made as routine," (JAMA, 1/25/1919). The bacterial flora of the nasopharynx of some patients was also cultured since droplet infection was where the disease disseminated. The collected swabs and specimens were inoculated onto blood agar of petri dishes. The grown up bacterial colonies were closely studied to find the causal organism. Commonly found were pneumococcus, streptococcus, staphylococcus and Bacillus influenzae (JAMA, 4/12/1919). These new laboratory tests used in the clinical setting brought in a solid scientific, biological link to the practice of medicine. Medicine had become fully scientific and technologic in its understanding and characterization of the influenza epidemic.

Treatment and Therapy

The therapeutic remedies for influenza patients varied from the newly developed drugs to oils and herbs. The therapy was much less scientific than the diagnostics , as the drugs had no clear explanatory theory of action. The treatment was largely symptomatic, aiming to reduce fever or pain. Aspirin, or acetylsalicylic acid was a common remedy. For secondary pneumonia doses of epinephrin were given. To combat the cyanosis physicians gave oxygen by mask or some injected it under the skin (JAMA, 10/3/1918). Others used salicin which reduced pain, discomfort and fever and claimed to reduce the infectivity of the patient. Another popular remedy was cinnamon in powder or oil form with milk to reduce temperature (BMJ, 10/19/1918). Finally, salt of quinine was suggested as a treatment. Most physicians agreed that the patient should be kept in bed (BMJ, 7/13/1918). With that was the advice of plenty of fluids and nourishment. The application of cold to the head, with warm packs or warm drinks was also advised. Warm baths were used as a hydrotherapeutic method in hospitals but were discarded for lack of success (JAMA, 10/3/1918). These treatments, like the suggested prophylactic measures of the public health officials, seemed to originate in the common social practices and not in the growing field of scientific medicine. It seems that as science was entering the medical field, it served only for explanatory, diagnostic and preventative measures such as vaccines and technical tests. This science had little use once a person was ill.

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However, a few proposed treatment did incorporate scientific ideas of germ theory and the immune system. O'Malley and Hartman suggested to treat influenza patients with the serum of convalescent patients. They utilize the theorized antibodies to boost the immune system of sick patients. Other treatments were "digitalis," the administration of isotonic glucose and sodium bicarbonate intravenously which was done in military camps (JAMA, 1/4/1919). Ross and Hund too utilized ideas about the immune system and properties of the blood to neutralize toxins and circulate white blood cells. They believed that the best treatment for influenza should aim to: "...neutralize or render the intoxicant inert...and prevent the blood destruction wit its destructive leukopenia and lessened coagulability," (JAMA, 3/1/1919). They tried to create a therapeutic immune serum to fight infection. These therapies built on current scientific ideas and represented the highest biomedical, technological treatment like the antitoxin to diphtheria.

The Etiology of Influenza in 1918

During the 1890 influenza epidemic, Pfeiffer found what he determined to be the microbial agent to cause influenza. In the sputum and respiratory tract of influenza patients in 1892, he isolated the bacteria Bacillus influenzae , which was accepted as the true "virus" though it was not found in localized outbreaks (BMJ, 11/2/1918). However, in studies of the 1907-8 epidemic in the US, Lord had found the bacillus in only 3 of 20 cases. He also found the bacillus in 30% of cultures of sputum from TB patients. Rosenthal further refuted the finding when he found the bacillus in 1 of 6 healthy people in 1900 (JAMA, 1/18/1919). The bacillus was also found to be present in all cases of whooping cough and many cases of measles, chronic bronchitis and scarlet fever (JAMA, 10/5/1918). The influenza pandemic provided scientists the opportunity to confirm or refute this contested microbe as the cause of influenza. The sputum studies from the Camp Lewis epidemic found only a few influenza cases harvesting the influenza bacilli and mostly type IV pneumococcus . They concluded that "the recent epidemic at Camp Lewis was an acute respiratory infection and not an epidemic due to Bacillus influenzae ," (JAMA, 1/25/1919). This finding along with others suggested to most scientists that the Pfeiffer's Bacillus was not the cause of influenza.

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In the 1918-19 influenza pandemic, there was a great drive to find the etiological agent responsible for the deadly scourge. Scientists in their labs were working hard, using the cultures obtained from physician clinics, to isolate the etiological agent for influenza. As a report early in the epidemic said, "the 'influence' of influenza is still veiled in mystery, " (JAMA, 10/5/1918). The nominated bacillus influenzae bacteria seemed to be incorrect and scientists scrambled to isolate the true cause. In the journals, many authors speculated on the type of agent-- was it a new microbe, was it a bacteria, was it a virus? One journal offered that "the severity of the present pandemic, the suddenness of onset...led to the suggestion that the disease cannot be influenza but some other and more lethal infection," (BMJ, 11/2/1918). However, most accepted that the epidemic disease was influenza based on the familiar symptoms and known pattern of disease. The respiratory disease of influenza was understood to give warning in the late spring of its potential effects upon its recrudescence once the weather turned cold in the winter (BMJ, 10/19/1918). One article with foresight stated that "there can be no question that the virus of influenza is a living organism...it is possibly beyond the range of microscopic vision," (BMJ, 11/16/1918). Another article confirmed the idea of an "undiscovered virus" and noted that pneumococccci and streptococci were responsible for "the gravity of the secondary pulmonary complications," (BMJ, 11/2/1918). The article went on to offer the idea of a symbiosis of virus and secondary bacterial infection combining to make it such a severe disease.

The investigators as they attempted to find the responsible agent for the influenza pandemic were developing ideas of infectious microbes and the concept of the virus. The idea of the virus as an infectious agent had been around for years. The articles of the period refer to the "virus" in their discussion but do not consistently use it to be an infectious microbe, distinctive from bacteria. The term virus has the same usage and application as bacillus. In 1918, a virus was defined scientifically to be a submicroscopic infectious entity which could be filtered but not grown in vitro . In the 1880s Pasteur developed an attenuated vaccine for the rabies virus by serial passage way ahead of his time. Ivanoski's work on the tobacco mosaic virus in 1890s lead to the discovery of the virus. He found an infectious agent that acted as a micro organism as it multiplied yet which passed through the sterilizing filter as a nonmicrobe. By the 1910s several viruses, defined as filterable infectious microbes, had been identified as causing infectious disease (Hughes). However, the scientists were still conceptually behind in defining a virus; they distinguished it only by size from a bacteria and not as an obligate parasite with a distinct life cycle dependent on infecting a host cell.

The influenza epidemic afforded the opportunity to research the etiological agent and develop the idea of the virus. Experiments by Nicolle and Le Bailly in Paris were the earliest suggestions that influenza was caused by a "filter-passing virus," (BMJ, 11/2/1918). They filtered out the bacteria from bronchial expectoration of an influenza patient and injected the filtrate into the eyes and nose of two monkeys. The monkeys developed a fever and a marked depression. The filtration was later administered to a volunteer subcutaneously who developed typical signs of influenza. They reasoned that the inoculated person developed influenza from the filtrate since no one else in their quarters developed influenza (JAMA, 12/28/1918). These scientists followed Koch's postulates as they isolated the causal agent from patients with the illness and used it to reproduce the same illness in animals. Through these studies, the scientists proved that influenza was due to a submicroscopic infectious agent and not a bacteria, refuting the claims of Pfeiffer and advancing virology. They were on their way to discerning the virus and characterizing the orthomyxo viruses that lead to the disease of influenza.

These scientific experiments which unravel the cause of influenza, had immediate preventative applications. They would assist in the effort to create a effective vaccine to prevent influenza. This was the ultimate goal of most studies, since vaccines were thought to be the best preventative solution in the early 20th century. Several experiments attempted to produce vaccines, each with a different understanding of the etiology of fatal influenza infection. A Dr. Rosenow invented a vaccine to target the multiple bacterial agents involved from the serum of patients. He aimed to raise the immunity to against the bacteria, the "common causes of death," and not the cause of the initial symptoms by inoculating with the proportions found in the lungs and sputum (JAMA, 1/4/1919). The vaccines made for the British forces took a similar approach and were "mixed vaccines" of pneumococcus and lethal streptococcus. The vaccine development therefore focused on the culture results of what could be isolated from the sickest patients and lagged behind the scientific progress.

Anthrax


Anthrax is a sometimes deadly infection caused by the bacterium Bacillus anthracis. This bacterium is housed in a spore — a cell that's dormant, but may become active in the right conditions. Anthrax usually affects livestock, but it also infects humans. Humans can become infected when handling products of infected animals, or if exposed to anthrax that's used as a biological weapon — such as when anthrax spores were deliberately spread in powder-containing envelopes through the U.S. postal system in 2001.

Anthrax infection can occur through a wound in the skin, by ingesting it or by inhaling it. Symptoms depend on which way you're infected and range from a sore on the skin to nausea and vomiting to shock. Early treatment with antibiotics can cure most anthrax infections spread through the skin and many of those spread by ingestion. Inhaled anthrax is the most difficult to treat and is often fatal.

There are three major anthrax syndromes: cutaneous, inhalational, and gastrointestinal anthrax. Cutaneous anthrax, which makes up 95% of naturally occurring infections, begins as a painless, pruritic papule that develops into a vesicle within 2 days.

As the vesicle enlarges, striking edema may form around it, and there is regional lymphadenopathy. After the vesicle ruptures, the remaining ulcer becomes covered with a characteristic black eschar, which dries and falls off as the patient recovers. Bacteremia is rare with cutaneous anthrax.

Inhalational anthrax occurs when spores are inhaled. The organism grows and is carried to lymph nodes by phagocytes where the spores germinate, and the release of toxins causes hemorrhagic mediastinitis.

After a prodromal illness of 1 to 6 days characterized by fever, cough, and chest or abdominal pain, there is abrupt onset of increased fever, hypoxia, and sweating. Frequently, anthrax meningitis develops due to bacteremia. Inhalational anthrax rapidly leads to shock and frequently death within 1 to 2 days.

Gastrointestinal anthrax is an uncommon form of this infection that is usually contracted by eating undercooked meat contaminated with B. anthracis. Initially, the patient has nausea, abdominal pain, and vomiting. Severe, bloody diarrhea rapidly develops, and mortality is over 50%.

Prevention

In addition to treating anthrax, antibiotics are recommended to prevent infection in anyone exposed to anthrax. Ciprofloxacin and doxycycline are FDA-approved for post-exposure prevention of anthrax in adults and children. Levofloxacin is approved for adults who've been exposed.

Anthrax vaccine
The FDA approved a human vaccine in 1970, which has mostly been used by military personnel. Vaccination consists of three shots given two weeks apart followed by three additional shots given at six, 12, and 18 months. Annual booster shots are recommended to maintain immunity.

The human anthrax vaccine doesn't contain live anthrax bacteria, so it can't cause the infection. Side effects may include soreness at the injection site, a flu-like reaction and possibly more-serious allergic reactions. The anthrax vaccine isn't recommended for children, pregnant women or older adults. It's an effective, but not a 100 percent protective vaccine.

The vaccine isn't available to the public. Instead, the vaccine is reserved for:

  • Active-duty U.S. military personnel who are deployed to areas with high risk of exposure to anthrax
  • People who work with anthrax in a laboratory setting
  • People who handle potentially infected animal products in areas of the world where anthrax is a threat to livestock
  • People who work with imported animal hides or furs from areas with a high incidence of anthrax

Scientists are working to produce a new anthrax vaccine. The new vaccine may require fewer doses and be available in large quantities.

Avoiding contact with infected animals
In countries where anthrax is common and vaccination levels of animal herds are low, it's wise to avoid contact with livestock and animal products and to avoid eating meat that hasn't been properly slaughtered and cooked.

Other preventive measures include carefully handling dead animals suspected of having the disease and providing good protection when processing hides, fur, wool or hair.

Risks

Anthrax isn't contagious. People who get inhalation anthrax don't exhale spores. There are no reports of the disease spreading from one person to another.

To contract anthrax, you must come in direct contact with anthrax spores. However, you can be exposed to anthrax spores and not become infected.

Treatment

Treatment for all three forms of anthrax depends on oral or intravenous (IV) antibiotics. Treatment is most effective when started as early as possible.

Some strains of anthrax may be more responsive to one type of antibiotic than to another. Ciprofloxacin (Cipro), doxycycline and penicillin are approved by the Food and Drug Administration (FDA) for treatment of anthrax in adults and children. However, your doctor may prescribe other antibiotics or a combination of antibiotics.

These medications work by killing the anthrax bacteria. However, antibiotics may fail in inhalation anthrax once symptoms become severe because the bacteria may already have released large amounts of toxin that aren't affected by antibiotics. Scientists are working to develop an anthrax antitoxin that could neutralize the toxin produced by anthrax bacteria.

If you've been exposed to anthrax, your doctor will likely prescribe a long course — 60 days or more — of antibiotics. If you have inhalation anthrax, you'll likely be hospitalized and treated with intravenous antibiotics.

Anthrax isn't spread person to person. So a person with anthrax doesn't have to be quarantined or isolated. If you were in contact with someone with anthrax, you'll need to be treated only if you were exposed to a source of anthrax infection.

Autoimmune hepatitis

Definition

In autoimmune hepatitis, your body's immune system attacks your liver. Although the reason for this isn't entirely clear, some diseases, toxins and drugs may trigger autoimmune hepatitis in susceptible people, especially women.

Untreated autoimmune hepatitis can lead to scarring of the liver (cirrhosis) and eventually to liver failure. When diagnosed and treated early, however, autoimmune hepatitis often can be controlled with drugs that suppress the immune system. Yet these medications, which often must be taken long term, carry a number of risks and aren't always effective. A liver transplant may be an option when autoimmune hepatitis doesn't respond to drug treatments or in cases of advanced liver disease.

Symptoms

Signs and symptoms of autoimmune hepatitis can range from minor to severe and may come on suddenly or develop over time. Some people have few, if any, problems in the early stages of the disease, whereas others experience signs and symptoms that may include:

  • Anemia
  • Fatigue
  • Abdominal discomfort
  • Joint aches (arthralgias)
  • Itching (pruritus)
  • Yellowing of the skin and whites of the eyes (jaundice)
  • An enlarged liver
  • Abnormal blood vessels on the skin (spider angiomas)
  • Nausea and vomiting
  • Liver scarring (cirrhosis)
  • Fluid in the abdomen (ascites)
  • Mental confusion

It's common for people with autoimmune hepatitis to have other autoimmune disorders, such as:

  • Hemolytic anemia, which occurs when red blood cells are destroyed faster than bone marrow can replace them
  • Chronic inflammation of the thyroid gland (thyroiditis)
  • Inflammation of the colon (ulcerative colitis)
  • Diabetes
  • Dry eyes and mouth (Sjogren's syndrome)
  • Celiac sprue, a condition that damages the small intestine and leads to an inability to absorb certain nutrients

Causes

In autoimmune hepatitis, the body's immune system, which ordinarily attacks viruses, bacteria and other pathogens, instead targets the liver. Your body's attack on your liver can lead to chronic inflammation and serious damage to liver cells. Just why the body turns against itself is unclear, but autoimmune hepatitis appears to be triggered by:

  • Infections. Autoimmune hepatitis can develop after such viral infections as acute hepatitis A, hepatitis B or measles or after infection with the Epstein-Barr virus. Epstein-Barr is one of the most common human viruses and linked to a number of disorders, including mononucleosis.
  • Certain drugs. Some medications injure the liver directly — overdoses of the common pain reliever acetaminophen (Tylenol, others), for example, can cause liver failure. Other drugs harm the liver indirectly by stimulating an abnormal immune response that then harms liver cells.
  • Genetic abnormalities. Some people seem genetically predisposed to develop autoimmune hepatitis. Researchers have identified certain gene abnormalities that increase the likelihood the disease will develop at a young age. Other genetic abnormalities may make autoimmune hepatitis more aggressive and harder to treat.

Types of autoimmune hepatitis
Doctors have identified two main forms of autoimmune hepatitis:

  • Type 1 (classic) autoimmune hepatitis. Often developing suddenly, this is the most common type of the disease. Although it can occur in anyone at any age, most of those affected are young women. About half the people with type 1 autoimmune hepatitis have other autoimmune disorders, such as thyroiditis, rheumatoid arthritis or ulcerative colitis. Their blood also is likely to contain antibodies against organ tissue.
  • Type 2 autoimmune hepatitis. Although adults can develop type 2 autoimmune hepatitis, it's most common in young girls and often occurs with other autoimmune problems.

Risk factors

Autoimmune hepatitis is uncommon. Having one or more risk factors for the disease doesn't mean that you'll develop it — only that you may be more susceptible than someone without these risk factors:

  • Your sex. Although both men and women can develop autoimmune hepatitis, the disease is far more common in women.
  • Age. Type 1 autoimmune hepatitis can occur in older adults, but it's most common in women between the ages of 15 and 40. Type 2 primarily affects young girls.
  • A history of certain viral infections. Autoimmune hepatitis may develop after a viral infection, especially hepatitis A or B, measles, or infection with the Epstein-Barr virus.
  • Use of certain medications. The high blood pressure drug methyldopa, the anti-inflammatory diclofenac, the antibiotics minocycline and nitrofurantoin, and perhaps atorvastatin (Lipitor) may trigger autoimmune hepatitis in some people.
  • Heredity. Certain genetic defects increase the risk of autoimmune hepatitis.

When to seek medical advice

Schedule an appointment with your doctor
Early signs and symptoms of autoimmune hepatitis can be mild and may resemble those of the flu. See your doctor if you have:

  • Persistent fatigue
  • Abdominal discomfort
  • Joint aches unrelated to exercise

See your doctor immediately
More serious symptoms require immediate care, especially if you have risk factors for autoimmune hepatitis. Such signs include:

  • Yellowing of your skin and the whites of your eyes
  • Abdominal swelling

Tests and diagnosis

Although your signs and symptoms can alert your doctor to the possibility of liver disease, you'll need certain tests to diagnose autoimmune hepatitis. These include:

  • Blood tests. Antibody tests can distinguish autoimmune hepatitis from viral hepatitis and other disorders with similar symptoms. They also help pinpoint the type of autoimmune hepatitis you have.
  • Liver biopsy. Doctors perform this test to confirm the diagnosis and to determine the degree and type of liver damage. During the procedure, a small amount of liver tissue is removed, using a thin needle that's passed into your liver through a small incision in your skin. The sample is then sent to a laboratory for analysis.
  • Imaging tests. An abdominal ultrasound or abdominal computerized tomography (CT) scan can't diagnose autoimmune hepatitis, but doctors sometimes use these tests to help diagnose cirrhosis and to rule out liver cancer, a complication of cirrhosis.

    Magnetic resonance elastography (MRE) is a relatively new imaging test that may help your doctor diagnose cirrhosis and may help avoid the need for liver biopsy, which is more invasive. MRE technology works by combining traditional magnetic resonance imaging (MRI) with low-frequency sounds waves. The MRI component uses a magnetic field and radio waves to create clear and detailed cross-sectional images of your body, which show size and structure of your tissues and organs. The low-frequency sound waves then help reveal physical properties of those tissues and organs — such as tissue stiffness. Stiffness of your liver may indicate cirrhosis.

Complications

Autoimmune hepatitis may be associated with a variety of complications or other conditions, including:

  • Pernicious anemia. Associated with a number of autoimmune disorders, pernicious anemia occurs when a lack of vitamin B-12 interferes with your body's ability to form red blood cells. Signs and symptoms of pernicious anemia can range from shortness of breath and a rapid heart rate to diarrhea, numbness or tingling in your hands and feet, and personality changes.
  • Hemolytic anemia. In this type of anemia, your immune system attacks and breaks down red blood cells faster than your bone marrow can replace them.
  • Thrombocytopenic purpura. Platelets are blood cells that play a crucial role in blood clotting. In thrombocytopenic purpura, your immune system attacks and destroys these cells, leading to easy bruising and bleeding.
  • Ulcerative colitis. This inflammatory bowel disease can cause severe bouts of watery or bloody diarrhea and abdominal pain. It occurs in as many as two in 10 people with type 1 autoimmune hepatitis.
  • Celiac disease. This disease causes an abnormal reaction to gluten, a protein found in most grains. Eating gluten sets off an immune response that damages the small intestine, affecting its ability to absorb nutrients.
  • Autoimmune thyroiditis (Hashimoto's thyroiditis). In this condition, the immune system attacks the thyroid gland. In some people this causes the gland to secrete too little thyroid hormone (hypothyroidism). In others, the gland initially produces too much hormone (hyperthyroidism) and then produces too little.
  • Type 1 diabetes. In type 1 diabetes, the immune system targets and destroys the insulin-producing cells in the pancreas. Insulin plays a vital role in making glucose — the body's fuel — available to cells. Without insulin, cells starve, and glucose builds up in the bloodstream. Diabetes is a serious illness that can damage organs throughout the body.
  • Rheumatoid arthritis. Another autoimmune disease, rheumatoid arthritis occurs when the immune system attacks the lining of your joints, leading to stiffness, pain, swelling, and sometimes to deformity and disability.

Because symptoms don't always appear in the early stages of the disease, some people with autoimmune hepatitis develop irreversible scarring of liver tissue (cirrhosis) before they're ever diagnosed. Complications of cirrhosis include:

  • Increased blood pressure in the vein that sends blood into the liver. Blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. If scar tissue blocks normal circulation through your liver, this blood backs up, leading to increased pressure within the portal vein (portal hypertension).
  • Enlarged veins (varices). When circulation through the portal vein is blocked, blood may back up into other blood vessels — mainly those in your stomach and esophagus. Sometimes veins also form around your navel and at the rectum. The blood vessels are thin walled, and because they're filled with more blood than they're meant to carry, they're likely to bleed. Massive bleeding in the upper stomach or esophagus from these blood vessels is a life-threatening emergency that requires immediate medical care.
  • Fluid retention. Liver disease can cause large amounts of fluid to accumulate in your legs (edema) and abdomen (ascites). Several factors play a role, including portal hypertension and changes in the hormones and chemicals that regulate fluids in your body. Ascites can be uncomfortable and may interfere with breathing and is usually a sign of advanced cirrhosis.
  • Bruising and bleeding. Scarring of the liver (cirrhosis) interferes with the production of proteins that help your blood clot and with the absorption of vitamin K, which plays a role in synthesizing these proteins. As a result you may bruise and bleed more easily than normal. Bleeding in the gastrointestinal tract is particularly common.
  • Mental changes. A damaged liver has trouble removing toxins from your body — normally one of the liver's key tasks. The buildup of toxins such as ammonia — a byproduct of protein digestion — can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Symptoms of hepatic encephalopathy include forgetfulness, confusion and mood changes.
  • Liver failure. This occurs when extensive damage to liver cells makes it impossible for your liver to function. At this point, a liver transplant is the only option.
  • Liver cancer. Cirrhosis is one of the most common causes of hepatocellular carcinoma, the main form of liver cancer.

Treatments and drugs

The goal in treating autoimmune hepatitis is to inhibit your body's autoimmune response and slow the progress of the disease.

Prednisone
To achieve this, doctors usually prescribe an initial high dose of the corticosteroid drug prednisone, which suppresses the immune system. As soon as signs and symptoms improve, the medication is reduced to the lowest possible dose that controls the disease. Most people need to continue taking the drug for years, and sometimes for life. Although you may experience remission a few years after starting treatment, the disease usually returns when the drug is discontinued.

Prednisone side effects
Prednisone, especially when taken long term, can cause a wide range of serious side effects, including:

  • Diabetes
  • Thinning bones (osteoporosis)
  • High blood pressure
  • Glaucoma
  • Difficulty fighting infection
  • Thinning of your hair and skin
  • Weight gain

Azathioprine (Imuran)
Because prednisone can cause such side effects, azathioprine, another immunosuppressant medication, is sometimes used along with prednisone. This helps lower the amount of prednisone needed, reducing its side effects.

Azathioprine (Imuran) side effects
Azathioprine has risks of its own, however, including:

  • Decreased resistance to infection
  • Nausea
  • Rarely, liver damage and inflammation of the pancreas
  • Rarely, cancer development after prolonged use

When these medications don't work
If you don't respond to these drugs or you have severe side effects, your doctor may prescribe cyclosporine or another immunosuppressant that may be effective. When medications don't halt the progress of the disease, or you have or develop irreversible scarring (cirrhosis) or liver failure, the remaining option is a liver transplant — a procedure that's often very successful in people with autoimmune hepatitis.

What Is Cancer Anyway?


Cancer begins when cells in a part of the body start to grow out of control. There are many kinds of cancer, but they all start because of out-of-control growth of abnormal cells.

Also cancer is a group of more than 100 diseases. Although each kind differs from the others in many ways, every type of cancer is a disease of some of the body's cells. Healthy cells that make up the body's tissues grow, divide, and replace themselves in an orderly way. This process keeps the body in good repair. Sometimes, however, some cells lose the ability to limit and direct their growth. They grow too rapidly and without any order. Too many cells are produced, and tumors are formed. Tumors can be either benign or malignant.

Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Benign tumors can often be removed by surgery, and they are not likely to return. Some tumors of the testicle are benign, but most are not.

Malignant tumors are cancer. They can invade and destroy nearby healthy tissues and organs. Cancerous cells can also spread, or metastasize, to other parts of the body and form new tumors.

Cancer that develops in a testicle is called testicular cancer. When testicular cancer spreads, the cancer cells are carried by blood or by lymph, an almost colorless fluid produced by tissues all over the body. The fluid passes through lymph nodes, which filter out bacteria and other abnormal substances such as cancer cells. Doctors use CT (computed tomography) scans of the abdomen and chest to help determine if the cancer has spread to the lymph nodes or lungs.

How a normal cell becomes cancer

Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide faster to allow the person to grow. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries.

Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, cancer cells outlive normal cells and keep forming new abnormal cells. Another difference between cancer cells and normal cells is that cancer cells can invade (grow into) other tissues. Being able to grow out of control and to invade other tissues makes a cell a cancer cell.

Cells become cancer cells because of damage to DNA. DNA is in every cell and directs all its actions. Most of the time, when DNA gets damaged the cell can fix it. If the cell can’t repair the damage, the cell dies. In cancer cells the damaged DNA is not repaired, but the cell doesn’t die like it should. Instead, this cell goes on making new cells even though the body does not need them. These new cells will all have the same DNA damage as the first cell does.

People can inherit damaged DNA, but most of the time DNA damage is caused by something we are exposed to in our environment. Sometimes the cause of the DNA damage is something obvious, like cigarette smoking. But many times no clear cause is found.

A cancer cell has many mistakes in its DNA -- having damage in just one spot does not cause cancer. Even when someone inherits damaged DNA, more mistakes in their DNA are needed before a cancer will develop. Staying away from things that are known to damage DNA (like smoking) as a part of a healthy life style lowers the chance that more DNA damage will take place. This can reduce the risk of cancer -- even in people who have an inherited tendency to get cancer.

How cancers grow and spread

In most cases the cancer cells form a tumor. Some cancers, like leukemia, do not form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow. But sometimes the extra cells in these blood cancers may also form a mass of tissue called a tumor.

Cancer cells often travel to other parts of the body, where they begin to grow and replace normal tissue. This process is called metastasis. It happens when the cancer cells get into the bloodstream or lymph vessels of our body.

But no matter where a cancer may spread, it is always named for the place where it started. For example, breast cancer that has spread to the liver is still called breast cancer, not liver cancer. Prostate cancer that has spread to the bone is metastatic prostate cancer, not bone cancer.

Not all tumors are cancerous. Tumors that aren't cancer are called benign. Benign tumors can cause problems -- they can grow very large and press on healthy organs and tissues. But they cannot grow into (invade) other tissues. Because they can't invade, they also can't spread to other parts of the body (metastasize). These tumors are almost never life threatening.

How cancers differ

Different types of cancer can behave very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That is why people with cancer need treatment that is aimed at their particular kind of cancer.

How common is cancer

Cancer is the second leading cause of death in the United States. Nearly half of all men and a little over one third of all women in the United States will develop cancer during their lifetimes.

Today, millions of people are living with cancer or have had cancer. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a better diet. Often, the sooner a cancer is found and treatment begins, the better are the chances for living for many years.

Last Medical Review: 02/24/2009
Last Revised: 02/24/2009

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