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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