DIPLOMA PHARMACY- PH 110 MICROBIOLOGY - PHC 122

DISEASES CAUSED BY PHATOGENIC MICROORGANISM IN LYMPHATIC SYSTEM

NAME : SYAKIRAH BINTI RASHID REDZA.

STUDENTS ID : 2010555067. GROUP : 1 M

INTRODUCTION Lymphatic System Diseases

The lymphatic system is a network of tissues and organs, which forms an important part of the body's immune system. Any malfunction or inflammation of this complex network can lead to different lymphatic system diseases or disorders. The lymphatic system comprises of lymph vessels, lymph nodes and lymph and is considered to be the second circulatory system in the body. The system circulates lymph around the body through lymphatic vessels (which are different from blood vessels) and lymph nodes. Lymph basically contains white blood cells that defend the body against germs and infections. Lymph nodes are oval or bean-shaped group of tissues that are located along the lymph vessels and abundantly found in the neck, armpit, groin, and around the large blood vessels in the abdomen and chest. It is the lymph nodes and spleen where these white blood cells (produced by the bone marrow and thymus) fight infection which improve the body'simmune system. More on lymph nodes: locations and functions.

Functions of Lymphatic System

The main function of the lymphatic system is to maintain the fluid and protein balance in the body. As blood travels through the arteries and veins, nearly 10% of the fluid filtered by the capillaries, along with vital proteins, gets trapped in the tissues of the body. This loss of fluid would rapidly become life threatening if the lymphatic system does not

collect this fluid and return it to the circulatory system. With the network of vessels and nodes that transport and filter lymph fluid containing antibiotics and white blood cells, the lymphatic system is considered to be the first line of defense against any infection or diseases from invading microorganisms. Lymph vessels in the lining of the gastrointestinal tract absorb fats from food and impacts disorders like excessive obesity, diabetes, etc, caused by abnormal fat and carbohydrate accumulation and metabolism. More on lymphatic system functions.

Diseases of the Lymphatic System

The lymphatic system, like other parts of the body, is also susceptible to a variety of diseases and disorders which are given below:

Lymphedema: One of the most prevalent lymphatic disorder is lymphatic insufficiency, or

lymphedema which occurs due to an accumulation of lymphatic fluid in the interstitial tissue. This results in swelling in the arms, legs and sometimes in other parts of the body. The severity of this disorder varies from extremely mild complications to a disfiguring, painful and cellulite infections deep in skin. If not treated, the skin eventually becomes fibrotic (thickening of the skin and subcutaneous tissues) with loss of normal structure, functionality and mobility. The two types of lymphedema are:

Primary Lymphedema: It is an inherited condition that occurs due to impaired or missing lymphatic vessels. It affects from one to as many as four limbs and even other body parts, including internal organs. It can exhibit at birth, develop with the onset of puberty or occur in adulthood, with no apparent causes.

Secondary Lymphedema: The disorder is basically acquired regional lymphatic insufficiency which occurs due to any trauma, infection or surgery that disrupts the lymphatic vessels or results in the loss of lymph nodes. More on lymphedema treatment.

Filariasis: Filariasis is another lymphatic system disorder that occurs from a parasitic-caused
infection causing lymphatic insufficiency, and in some cases predisposes elephantiasis (thickening of the skin and underlying tissues especially in the legs, male genitals and female breasts).

Lymphoma: Lymphoma is a medical term used for a group of cancers that originate in the
lymphatic system. Lymphomas usually begin with malignant transformation of the lymphocytes (white blood cells) in lymph nodes or bunch of lymphatic tissue in organs like the stomach or

intestines. Hodgkin lymphoma and non-Hodgkin lymphoma are two major categories in Lymphoma, characterized by enlargement of lymph nodes, usually present in the neck. Symptoms of lymphoma mainly include chronic fatigue, weak immune function, weight loss, night sweats and pain after drinking alcohol.

Lymphadenopathy: Lymphadenopathy is a lymphatic disorder in which the lymph nodes

become swollen or enlarged, due an infection. For example, swollen lymph nodes in the neck may occur as a result of a throat infection.

Lymphadenitis: Also known as adenitis, Lymphadenitis is an inflammation of the lymph

node due to a bacterial infection of the tissue in the node causing swelling, reddening, and tenderness of the skin overlying the lymph node.

Splenomegaly: Splenomegaly or enlarged spleen is another lymphatic system disorder, that

develops due to a viral infection like mononucleosis.

Tonsillitis: Of many other lymphatic system disorders, tonsillitis is another disease caused by
an infection of the tonsils, the lymphoid tissues present in the back of the mouth at the top of the throat. These lymphoid tissues help filter out bacteria and when infected, they become swollen and inflamed, leading to a sore throat, fever, and difficulty and pain while swallowing. HIV/AIDS and inflammatory and auto-immune diseases like rheumatoid arthritis, systemic lupus erythematosis (SLE), scleroderma, Wegener's granulomatosis, etc., are directly impacted by the lymphatic system. Hence, lymphatic insufficiency of the internal organs and unhealthy lifestyles can eventually lead to any of the aforementioned lymphatic system diseases.

1. Filariasis

Filariasis (Philariasis) is a parasitic disease and is considered an infectious tropical disease, that is caused by thread-like filarial nematodes (roundworms) in the superfamily Filarioidea, also known as "filariae". There are 9 known filarial nematodes which use humans as their definitive host. These are divided into 3 groups according to the niche within the body that they occupy: lymphatic filariasis', 'subcutaneous filariasis', and 'serous cavity filariasis'. Lymphatic filariasis is caused by the worms Wuchereria bancrofti, Brugia malayi, and Brugia timori. These worms occupy the lymphatic system, including the lymph nodes, and in chronic cases these worms lead to the disease elephantiasis. Subcutaneous filariasis is caused by loa loa (the African eye worm),Mansonella streptocerca, Onchocerca volvulus, and Dracunculus medinensis (the guinea worm). These worms occupy the subcutaneous layer of the skin, in the fat layer. Serous cavity filariasis is caused by the worms Mansonella perstans and Mansonella ozzardi, which occupy the serous cavity of the abdomen. In all cases, the transmitting vectors are either blood sucking insects (flies or mosquitoes), or copepod crustaceans in the case of Dracunculus medinensis.

Individuals infected by filarial worms may be described as either "microfilaraemic" or "amicrofilaraemic," depending on whether or not microfilaria can be found in their peripheral blood. Filariasis is diagnosed in microfilaraemic cases primarily through direct observation of microfilaria in the peripheral blood. Occult filariasis is diagnosed in amicrofilaraemic cases based on clinical observations and, in some cases, by finding a circulating antigen in the blood.

Signs and symptoms

The most spectacular symptom of lymphatic filariasis is elephantiasisedema with thickening of the skin and underlying tissueswhich was the first disease discovered to be transmitted by mosquito bites. Elephantiasis results when the parasites lodge in the lymphatic system.

Elephantiasis affects mainly the lower extremities, while the ears, mucus membranes, and amputation stumps are affected less frequently. However, different species of filarial worms tend to affect different parts of the body: Wuchereria bancrofti can affect the legs, arms, vulva, breasts, and scrotum (causing hydrocele formation) while Brugia timori rarely affects the genitals Interestingly, those who develop the chronic stages of elephantiasis are usually amicrofilaraemic, and often have adverse immunological reactions to the microfilaria, as well as the adult worm.

Diagnosis
Filariasis is usually diagnosed by identifying microfilariae on Giemsa stained thin and thick blood film smears, using the "gold standard" known as the finger prick test. The finger prick test draws blood from the capillaries of the finger tip; larger veins can be used for blood extraction, but strict windows of the time of day must be observed. Blood must be drawn at appropriate times, which reflect the feeding activities of the vector insects. Examples are W. bancrofti, whose vector is a mosquito; night time is the preferred time for blood collection. Loa loa's vector

is the deer fly; daytime collection is preferred. This method of diagnosis is only relevant to microfilariae that use the blood as transport from the lungs to the skin. Some filarial worms, such as M. streptocerca and O. volvulus produce microfilarae that do not use the blood; they reside in the skin only. For these worms, diagnosis relies upon skin snips, and can be carried out at any time.

Prevention
In 1993, the International Task Force for Disease Eradication declared lymphatic filariaisis to be one of six potentially eradicable diseases.Studies have demonstrated that transmission of the infection can be broken when a single dose of combined oral medicines is consistently maintained annually for approximately seven years. With consistent treatment, and since the disease needs a human host, the reduction of microfilariae means the disease will not be transmitted, the adult worms will die out, and the cycle will be broken. The strategy for eliminating transmission of lymphatic filariasis is mass distribution of medicines that kill the microfilariae and stop transmission of the parasite by mosquitoes in endemic communities. In sub-Saharan Africa, albendazole (donated by GlaxoSmithKline) is being used with ivermectin (donated by Merck & Co.) to treat the disease, whereas elsewhere in the world albendazole is used withdiethylcarbamazine. Using a combination of treatments better reduces the number of microfilariae in blood.[4] Avoiding mosquito bites, such as by using insecticidetreated mosquito bed nets, also reduces the transmission of lymphatic filariasis.. The efforts of the Global Programme to Eliminate LF are estimated to have prevented 6.6 million new filariasis cases from developing in children between 2000 and 2007, and to have stopped the progression of the disease in another 9.5 million people who had already contracted it.

Treatment
The recommended treatment for patients outside the United States is albendazole (a broad spectrum anthelmintic) combined withivermectin. A combination of diethylcarbamazine (DEC) and albendazole is also effective. All of these treatments are microfilaricides, they have no effect on the adult worms. In 2003 the common antibiotic doxycycline was suggested for treating elephantiasis. Filarial parasites have symbiotic bacteria in the genus Wolbachia, which live inside the worm and which seem to play a major role in both its reproduction and the development of the disease. Clinical trials in June 2005 by the Liverpool School of Tropical Medicine reported that an 8 week course almost completely eliminated microfilaraemia

2. .Lymphadenitis Definition
Lymphadenitis is the inflammation of lymph nodes. It is often a complication of bacterial infections, although it can also be caused by viruses or other disease agents. Lymphadenitis may be either generalized, involving a number of lymph nodes, or limited to a few nodes in the area of a localized infection. Lymphadenitis is sometimes accompanied by lymphangitis, which is the inflammation of the lymphatic vessels that connect the lymph nodes.

Description
The lymphatic system is a network of vessels (channels), nodes (glands), and organs. It is part of the immune system, which protects against and fights infections, inflammation, and cancers. The lymphatic system also participates in the transport of fluids, fats, proteins, and other substances throughout the body. The lymph nodes are small structures that filter the lymph fluid and contain many white blood cells to fight infections. Lymphadenitis is marked by swollen lymph nodes that develop when the glands are overwhelmed by bacteria, virus, fungi, or other organisms. The nodes may be tender and hard or soft and "rubbery" if an abscess has formed. The skin over an inflamed node may be red and hot. The location of the affected nodes is usually associated with the site of an underlying infection, inflammation, or tumor. In most cases, the infectious organisms are Streptococci or Staphylococci . If the lymphatic vessels are also infected, in a condition referred to as lymphangitis, there will be red streaks extending from the wound in the direction of the lymph nodes, throbbing pain , and high fever and/or chills. The child will generally feel ill, with loss of appetite, headache , and muscle aches. The extensive network of lymphatic vessels throughout the body and their relation to the lymph nodes helps to explain why bacterial infection of the nodes can spread rapidly to or from other parts of the body. Lymphadenitis in children often occurs in the neck area because these lymph nodes are close to the ears and throat, which are frequent locations of bacterial infections in children.

Demographics
Lymphadenitis and lymphangitis are common complications of bacterial infections.

Causes and symptoms

Streptococcal and staphylococcal bacteria are the most common causes of lymphadenitis, although viruses, protozoa, rickettsiae, fungi, and the tuberculosis bacillus can also infect the lymph nodes. Diseases or disorders that involve lymph nodes in specific areas of the body include rabbit fever (tularemia), cat-scratch disease , lymphogranuloma venereum, chancroid, genital herpes, infected acne , dental abscesses, and bubonic plague. Lymphadenitis can also occur in conjunction with cellulitis, which is a deep, widespread tissue infection that develops from a cut or sore. In children, tonsillitis or bacterial sore throats are the most common causes of lymphadenitis in the neck area. Diseases that involve lymph nodes throughout the body include mononucleosis, cytomegalovirus infection , toxoplasmosis , and brucellosis. The early symptoms of lymphadenitis are swelling of the nodes caused by a build-up of tissue fluid and an increased number of white blood cells resulting from the body's response to the infection. Further developments include fever with chills, loss of appetite, heavy perspiration, a rapid pulse, and general weakness.

Diagnosis
Physical examination The diagnosis of lymphadenitis is usually based on a combination of the child's medical history, external symptoms, and laboratory cultures. The doctor will press (palpate) the affected lymph nodes to see if they are sore or tender, and search for an entry point for the infection, like a scratch or bite. Swollen nodes without soreness are sometimes caused by cat-scratch disease, which is an uncommon illness. In children, if the lymphadenitis is severe or persistent, the doctor may need to rule out Although lymphadenitis is usually diagnosed in lymph nodes in the neck, arms, or legs, it can also occur in lymph nodes in the chest or abdomen. If the child has acutely swollen lymph nodes

in the groin, the doctor will need to rule out a hernia in the groin that has failed to reduce (incarcerated inguinal hernia). Hernias occur in 1 percent of the general population; 85 percent of children with hernias are male.

Treatment
Medications
The medications given for lymphadenitis vary according to the bacterium or virus that causes it. For bacterial infections, the child will be treated with antibiotics , usually a penicillin, clindamycin, a cephalosporin, or erythromycin.

Supportive care
Supportive care of lymphadenitis includes resting the affected area and applying hot moist compresses to reduce inflammation and pain.

Surgery
Cellulitis associated with lymphadenitis should not be treated surgically because of the risk of spreading the infection. Pus is drained only if there is an abscess and usually after the child has begun antibiotic treatment. In some cases, biopsy of an inflamed lymph node is necessary if no diagnosis has been made and no response to treatment has occurred. Inflammation of lymph nodes due to other diseases requires treatment of the underlying causes.

Prevention
Prevention of lymphadenitis depends on prompt treatment of bacterial and viral infections.

3. Tonsillitis

Tonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics.

Symptoms
Common symptoms of tonsillitis include:

red and/or swollen tonsils white or yellow patches on the tonsils tender, stiff, and/or swollen neck sore throat painful or difficult swallowing cough headache sore eyes body aches otalgia

fever chills nasal congestions

Acute tonsillitis is caused by both bacteria and viruses and will be accompanied by symptoms of ear pain when swallowing, bad breath, and drooling along with sore throat and fever. In this case, the surface of the tonsil may be bright red or have a grayish-white coating, while the lymph nodes in the neck may be swollen.

Causes
The most common causes of tonsillitis are the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, respiratory syncytial virus). It can also be caused by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV. The second most common causes are bacterial. The most common bacterial cause is Group A -hemolytic streptococcus (GABHS), which causes strep throat. Less common bacterial causes include: Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, pertussis, Fusobacterium, diphtheria, syphilis, and gonorrhea. Under normal circumstances, as viruses and bacteria enter the body through the nose and mouth, they are filtered in the tonsils. Within the tonsils, white blood cells of the immune system mount an attack that helps destroy the viruses or bacteria, and also causes inflammation and fever. The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx. This is the area in the back of the throat that lies between the voice box and the tonsils. Tonsillitis may be caused by Group A streptococcal bacteria, resulting in strep throat. Viral tonsillitis may be caused by numerous viruses such as the Epstein-Barr virus (the cause of infectious mononucleosis) or adenovirus. Sometimes, tonsillitis is caused by an infection of spirochaeta and treponema, in this case called Vincent's angina or Plaut-Vincent angina.

Treatment
Treatments to reduce the discomfort from tonsillitis symptoms include:

pain relief, anti-inflammatory, fever reducing medications (acetaminophen/paracetamol sore throat relief (salt water gargle, lozenges, warm liquids)

and/or ibuprofen)

If the tonsillitis is caused by group A streptococus, then antibiotics are useful with penicillin or amoxicillin being first line. A macrolidesuch as erythromycin is used for patients allergic to penicillin. Patients who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria such as clindamycin or amoxicillinclavulanate. Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins. When tonsillitis is caused by a virus, the length of illness depends on which virus is involved. Usually, a complete recovery is made within one week; however may last for up to two weeks. Chronic cases may be treated with tonsillectomy (surgical removal of tonsils) as a choice for treatment.

4. Lymphedema

Lymphedema refers to swelling that generally occurs in one of your arms or legs. Although lymphedema tends to affect just one arm or leg, sometimes both arms or both legs may be swollen. Lymphedema is caused by a blockage in your lymphatic system, an important part of your immune and circulatory systems. The blockage prevents lymph fluid from draining well, and as the fluid builds up, the swelling continues. There's no cure for lymphedema, but it can be controlled. Controlling lymphedema involves diligent care of your affected limb.

Signs and symptoms

Symptoms may include severe fatigue, a heavy swollen limb or localized fluid accumulation in other body areas, including the head or neck, discoloration of the skin overlying the lymphedema, and eventually deformity (elephantiasis). Lymphedema should not be confused with edema arising from venous insufficiency, which is not lymphedema. However, untreated venous insufficiency can progress into a combined venous/lymphatic disorder which is treated the same way as lymphedema. Presented here is an extreme case of severe unilateral hereditary lymphedema which had been present for 25 years without treatment:

Causes
Lymphedema may be inherited (primary) or caused by injury to the lymphatic vessels (secondary). It is most frequently seen after lymph node dissection, surgery and/or radiation therapy, in which damage to the lymphatic system is caused during the treatment of cancer, most notably breast cancer. In many patients with cancer, this condition does not develop until months or even years after therapy has concluded. Lymphedema may also be associated with accidents or certain diseases or problems that may inhibit the lymphatic system from functioning properly. In tropical areas of the world, a common cause of secondary lymphedema is filariasis, a parasitic infection. It can also be caused by a compromising of the lymphatic system resulting from cellulitis. While the exact cause of primary lymphedema is still unknown, it generally occurs due to poorly developed or missing lymph nodes and/or channels in the body. Lymphedema may be present at birth, develop at the onset of puberty (praecox), or not become apparent for many years into adulthood (tarda). In men, lower-limb primary lymphedema is most common, occurring in one or both legs. Some cases of lymphedema may be associated with other vascular abnormalities. Secondary lymphedema affects both men and women. In women, it is most prevalent in the upper limbs after breast cancer surgery andlymph node dissection, occurring in the arm on the side of the body in which the surgery is performed. Head and neck lymphedema can be caused by surgery or radiation therapy for tongue or throat cancer. It may also occur in the lower limbs or groin after surgery for colon, ovarian or uterine cancer, in which removal of lymph nodes or radiation therapy is required. Surgery or treatment for prostate, colon and testicular cancers may result in secondary lymphedema, particularly when lymph nodes have been removed or damaged. The onset of secondary lymphedema in patients who have had cancer surgery has also been linked to aircraft flight (likely due to decreased cabin pressure). For cancer survivors, therefore, wearing a prescribed and properly fitted compression garment may help decrease swelling during air travel. Some cases of lower-limb lymphedema have been associated with the use of tamoxifen, due to the blood clots and deep vein thrombosis(DVT) that can be caused by this medication. Resolution of the blood clots or DVT is needed before lymphedema treatment can be initiated.

Treatment
Treatment for lymphedema varies depending on the severity of the edema and the degree of fibrosis of the affected limb. Most people with lymphedema follow a daily regimen of treatment as suggested by their physician or certified lymphedema therapist. The most common treatments for lymphedema are a combination of manual compression lymphatic massage, compression garments or bandaging. Complex decongestive physiotherapy is an empiric system of lymphatic massage, skin care, and compressive garments. Although a combination treatment program may be ideal, any of the treatments can be done individually.

Prevention
If you're at risk of developing secondary lymphedema, you can take measures to help prevent it. If you've had or are going to have cancer surgery, ask your doctor whether your particular procedure will involve your lymph nodes or lymph vessels. Ask if your radiation treatment will be aimed at any of your lymph nodes, so you'll be aware of the possible risks. To reduce your risk of lymphedema, try to:

Protect your arm or leg. Avoid any injury to your affected limb. Cuts, scrapes and burns can all invite infection, which can result in lymphedema. Protect yourself from sharp objects. Rest your arm or leg while recovering. After cancer treatment, avoid heavy activity with that limb. Early exercise and stretching are encouraged, but avoid strenuous activity until you've recovered from surgery or radiation. Avoid heat on your arm or leg. Don't apply heat, such as with a heating pad, to your affected limb. Elevate your arm or leg. When you get a chance, elevate your affected limb above the level of your heart, if possible. Avoid tight clothing. Avoid anything that could constrict your arm or leg, such as tightfitting clothing and, in the case of your arm, blood pressure readings. Ask that your blood pressure be taken in your other arm. Keep your arm or leg clean. Make skin care and nail care high priorities. Inspect the skin on your arm or leg every day, keeping watch for changes or breaks in your skin that could lead to infection. Don't go barefoot outdoor

conclusion
When the lymphatic impairment becomes so great that the lymph fluid exceeds the lymphatic system's ability to transport it, an abnormal amount of protein-rich fluid collects in the tissues of the affected area. Left untreated, this stagnant, protein-rich fluid causes tissue channels to increase in size and number, reducing the availability of oxygen. This interferes with wound healing and provides a rich culture medium for bacterial growth that can result in infections: cellulitis, lymphangitis, lymphadenitis, filariasis and in severe cases, skin ulcers. It is vital for lymphedema patients to be aware of the symptoms of infection and to seek treatment at the first signs, since recurrent infections or cellulitis, in addition to their inherent danger, further damage the lymphatic system and set up a vicious circle. In rare cases, lymphedema can lead to a form of cancer called lymphangiosarcoma, although the mechanism of carcinogenesis is not understood. Lymphedema-associated lymphangiosarcoma is called Stewart-Treves syndrome. Lymphangiosarcoma most frequently occurs in cases of longstanding lymphedema. The incidence of angiosarcoma is estimated to be 0.45% in patients living 5 years after radical mastectomy. Lymphedema is also associated with a low grade form of cancer called retiform hemangioendothelioma (a low grade angiosarcoma) Since lymphedema is disfiguring, causes difficulties in daily living and can lead to lifestyle becoming severely limited, it may also result in psychological distress.

Reference

1. http://www.nlm.nih.gov/medlineplus/lymphaticdiseases.html 2. http://en.wikipedia.org/wiki/Lymphatic_disease 3. Microbiology (Essentials) by Tammy McCormick, Research & Education Association and Essentials,1998