The Middle East Respiratory Syndrome (MERS) is a respiratory disease caused by a newly recognized coronavirus, MERS-CoV.


The Middle East Respiratory Syndrome (MERS) is a respiratory disease caused by a newly recognized coronavirus, MERS-CoV. It was first reported in 2012 in Saudi Arabia and is thus far linked to countries in or near the Arabian Peninsula. Laboratory-confirmed MERS has now been identified in Bahrain, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates (UAE), and Yemen.

A large MERS outbreak occurred in the Republic of South Korea linked to a traveler from the Arabian Peninsula in 2015. Travel-associated cases have been identified in Algeria, Austria, China, Egypt, France, Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia, Turkey, United Kingdom (UK), and United States (US).

Transmission of Middle East respiratory Syndrome

Non-human to human transmission: The route of transmission from animals to humans is not fully understood, but dromedary camels are the major reservoir host for MERS-CoV and an animal source of infection in humans. Strains of MERS-CoV that are identical to human strains have been isolated from dromedaries in several countries, including Egypt, Oman, Qatar, and Saudi Arabia.

Human-to-human transmission: The virus does not pass easily from person to person unless there is close contact, such as providing unprotected care to an infected patient. There have been clusters of cases in healthcare facilities, where human-to-human transmission appears to have occurred, especially when infection prevention and control practices are inadequate or inappropriate. Human to human transmission has been limited to date and has been identified among family members, patients, and health care workers. While the majority of MERS cases have occurred in health care settings, thus far, no sustained human to human transmission has been documented anywhere in the world.

Middle East Respiratory Syndrome – Pathophysiology

One of the most important cells of the innate immune system is the macrophage. Its function is to eliminate pathogens, to present antigens to T cells, to produce cytokines and chemokines to maintain homeostasis and to modulate the immune response in tissues.

Compared with severe acute respiratory syndrome coronavirus (SARS-Cov), MERS-CoV can establish infection in monocyte-derived macrophages (MDMs) and macrophages. The virus induces the release of proinflammatory cytokines, leading to severe inflammation and tissue damage, which may manifest clinically as severe pneumonia and respiratory failure. Vascular endothelial cells located in the pulmonary interstitium may also be infected by MERS-CoV, and, because MERS-CoV receptor DPP4 is expressed in different human cells and tissues, dissemination of the infection may occur. This may explain the increased severity and higher fatality rate compared with SARS-CoV infection.

Interestingly, lymphopenia has been noted in most patients infected with MERS-CoV, as was noted in SARS infections. This is due to cytokine-induced immune cell sequestration and release and induction of monocyte chemotactic protein-1 (MCP-1) and interferon-gamma-inducible protein-10 (IP-10), which suppresses the proliferation of human myeloid progenitor cells.

Causes of Middle East Respiratory Syndrome

Research suggests that MERS-CoV originated in bats. It then likely spread from infected dromedary camels to humans.

According to the World Health Organization (WHO), most cases of MERS in humans have been transmitted by people in healthcare environments. However, evidence suggests that dromedary camels could also be a source of infection in humans.

The virus does not seem to pass easily from person to person unless there is close contact, as in a healthcare setting.

Researchers do not yet know how exactly camels are involved in transmitting this virus. They have identified MERS-CoV in camels in several countries in the Middle East, Africa, and South Asia.

What are the risk factors for MERS-CoV infection?

MERS-CoV can infect a person regardless of his/her health status or age group.

Recent travelers from the Arabian Peninsula and neighboring countries who develop severe acute respiratory infection should be tested for MERS-CoV.

Elderly people and those with underlying medical conditions such as diabetes, heart disease, or liver disease are at risk of severe infection.

Close association with any person infected with MERS-CoV, as in caregivers, health-care workers, or household contacts, is a major risk factor.

Contact with camel body fluids, respiratory secretions, raw or undercooked meat, and unpasteurized dairy products likely also poses a major risk of transmission to humans in the Arabian Peninsula and surrounding countries. Thus, those who work in these areas and handle live camels, or camel’s meat or milk are at risk, including veterinarians and those who work at markets or race tracks, and those who slaughter, butcher, milk, and cook raw camel products.

Cooked meat and pasteurized milk are safe to handle and consume. Not all camels may transmit the disease; Bactrian (Mongolian) camel herds currently show no infections with MERS, but researchers are not sure these camels have ever been exposed to the virus.

Symptoms – Middle East Respiratory Syndrome

  • The most common symptoms of MERS are fever, cough, and shortness of breath. People may also have gastrointestinal problems, such as diarrhea, nausea, or vomiting.
  • Pneumonia is a common complication. There have also been reports of organ failure linked with MERS, especially kidney failure.
  • The symptoms usually appear 5–6 days after exposure to the virus, but they may take 2–14 days to arise.
  • Some people transmit the virus without experiencing any symptoms, while some others with MERS experience minor symptoms.
  • People with severe symptoms may need to spend a long time in the hospital, receiving mechanical ventilation and intensive care.

What are the possible complications from MERS?

In some cases, MERS can cause severe problems. These are more of a risk for older adults. They are also a risk for people who have a weak immune system or a chronic illness like diabetes, cancer, or lung disease. The problems can include:

  • Lung infection (pneumonia)
  • Breathing (respiratory) failure and need for a breathing machine (ventilator)
  • Failure of the kidneys and other organs
  • Widespread infection and low blood pressure (septic shock)
  • These severe complications are more likely to lead to death from MERS.

How is Middle East Respiratory Syndrome diagnosed?

The healthcare providers will ask about your medical history. They will also ask about when you were exposed to MERS. They may ask about your recent travel and contact with sick people. They may also ask about recent contact with camels.

You will have tests to check for the cause of your symptoms. The symptoms of MERS can also be caused by other illnesses. You may have tests such as:

Chest X-ray. X-rays use a small amount of radiation to make images of the inside of your body. A chest X-ray is done to check for problems in your lungs.

Blood tests. Blood is taken from a vein in your arm or hand. This is done to check for certain chemicals that can show if you have the MERS virus or other illness.

Nasal or throat swab. A stick with a small piece of cotton at the tip is wiped inside your nose or throat. This is done to check for viruses in your nasal mucus.

Stool culture. A small sample of stool is collected from your rectum or from a bowel movement. The sample is checked for the virus.

Sputum culture. A small sample of mucus coughed from your lungs is collected. It is checked for the virus.

How Middle East Respiratory Syndrome is treated?

There is no approved treatment specifically for MERS. Most patients with the mild disease recover without complications. Patients with milder form can be treated at home and take medication for symptoms such as fever and pain. They should stay isolated to avoid spreading the disease. In more severe cases, the patient may develop lung or respiratory failure which requires them to be hospitalized. Doctors may suggest using a breathing tube, a mechanical ventilator or respirator, antibiotics, and intravenous fluids.

There is no current vaccine to protect people against MERS. Updates about potential vaccinations and treatment for MERS can be found on the CDC website and the World Health Organization website.

Treatment for MERS is done to help support your body while it fights the disease. This is known as supportive care. Supportive care may include:

  • Pain medicines. These include acetaminophen and ibuprofen. They are used to help ease pain and reduce fever.
  • Bed rest. This helps your body fight the illness.

Care during severe illness may include:

  • IV fluids. These are given through a vein to help keep your body hydrated.
  • Supplemental oxygen or assisted ventilation may be given. This is done to keep enough oxygen in your body.
  • Vasopressor medicine. These help to raise blood pressure that is too low from shock.

Prevention of Middle East Respiratory Syndrome

To reduce the risk of MERS-CoV transmission, health authorities recommend:

  • Frequently washing the hands with soap and water for at least 20 seconds at a time
  • Avoiding undercooked meats and any food prepared in conditions that may not be hygienic
  • Washing fruits and vegetables thoroughly
  • Reporting any suspected cases to local health authorities
  • Minimizing close contact with anyone who develops an acute respiratory illness with fever
  • Wearing a medical mask
  • Sneezing into a sleeve, flexed elbow, or a tissue, then immediately disposing of it
  • Seeking immediate medical attention if an acute respiratory illness with a fever develops within 14 days of returning from travel

MERS-CoV is contagious, but the virus does not appear to pass between humans without close contact.

The WHO state that it is safe to consume camel meat and milk after appropriate pasteurization, cooking, or other heat treatments, but it may be advisable to avoid raw products.

They recommend general hygiene practices after visiting farms or markets where camels are present, such as washing the hands before and after touching the animals and avoiding contact with sick animals.

Travelers with chronic conditions, such as diabetes, renal failure, or chronic lung disease have a higher risk of contracting the virus and should take extra precautions.

Mirizzi syndrome is a rare condition caused by the compression of the common hepatic duct due to stones located in the cystic duct or the neck.


Mirizzi syndrome is a rare condition caused by the compression of the common hepatic duct due to stones located in the cystic duct or the neck of the gallbladder, which causes obstruction of the extrahepatic biliary tract, what is most commonly presented as jaundice and upper abdominal pain. Mirizzi syndrome occurs approximately in 0.05-4% of patients undergiong cholecystectomy. Prolonged inflammation caused by the stones impacted in the cystic duct or the neck of the gallbladder may lead to advanced stages of Mirizzi syndrome and the formation of a cholecystocholedochal fistula or even a cholecystoenteric fistula. Diagnosis is made upon the symptoms, laboratory results and imaging techniques such as ultrasonography, computed tomography, magnetic resonance imaging or endoscopic retrograde choleangiopancreatography (ERCP), which is considered as the golden standard. However, the preoperative diagnosis is difficult and a large part of all cases is diagnosed intraoperatively. Management of Mirizzi syndrome is mostly surgical, but early stages of the syndrome can be treated with the use of ERCP.


Mirizzi’s syndrome occurs in approximately 0.1% of patients with gallstones. It is found in 0.7 to 2.5 percent of cholecystectomies. It affects males and females equally, but tends to affect older people more often. There is no evidence of race having any bearing on the epidemiology.


The gallbladder consists of the fundus, body, infundibulum, and neck. The body extends from the fundus into the tapered portion, or neck. The neck usually forms a gentle curve, the convexity of which forms the infundibulum, or Hartmann’s pouch. The gallbladder is connected at its neck to the cystic duct which empties into the common bile duct. Large gallstones can become impacted in the cystic duct or the infundibulum. These stones can produce common hepatic duct obstruction by mechanical obstruction of the hepatic duct because of the proximity of the cystic duct and the common hepatic duct, and secondary inflammation with frequent episodes of cholangitis. In rare cases, chronic inflammation may result in bile duct wall necrosis and erosion of the anterior or lateral wall of the common bile duct by impacted stones leading to cholecystobiliary (cholecystohepatic or cholecystocholedochal) fistula.

Types of Mirizzi syndrome

There are two classifications that are usually used to clarify the variants of Mirizzi syndrome and to aid in choosing the appropriate therapeutic procedure:

The original classification by McSherry described two types of Mirizzi syndrome:

Type I – Compression of the common hepatic duct or common bile duct by a stone impacted in the cystic duct or Hartmann’s pouch.

Type II – Erosion of the calculus from the cystic duct into the common hepatic duct or common bile duct, producing a cholecystocholedochal fistula.

A more useful classification system also takes into account the presence and extent of a cholecystobiliary (cholecystohepatic or cholecystocholedochal) fistula, also known as a biliobiliary fistula, due to erosion of the anterior or lateral wall of the common bile duct by impacted stones:

  • Type I – External compression of the common hepatic duct due to a stone impacted at the neck of the gallbladder or at the cystic duct.
  • Type II – The fistula involves less than one-third of the circumference of the common bile duct.
  • Type III – Involvement of between one-third and two-thirds of the circumference of the common bile duct.
  • Type IV – Destruction of the entire wall of the common bile duct

Risk factors

  • A cystic duct with low insertion into the common bile duct has been described as a risk factor for Mirizzi Syndrome.
  • A tortuous cystic duct is also thought to be a risk factor.

Causes of Mirizzi syndrome

  • Gallstones are usually formed from bile that is in stasis. When bile is not fully emptied from the gallbladder, it can precipitate as sludge and subsequently turn into stones.
  • Biliary obstruction may also lead to gallstones, including bile duct strictures and cancers, such as pancreatic cancer.
  • The most common cause of cholelithiasis is the precipitation of cholesterol that subsequently forms into cholesterol stones.
  • The second form of gallstones is pigmented gallstones, which result from increased red blood cell destruction in the intravascular system causing increased concentrations of bilirubin, which subsequently get stored in the bile. These stones are typically black.
  • The third type of gallstones is mixed pigmented stones, a combination of calcium substrates such as calcium carbonate or calcium phosphate, cholesterol, and bile.
  • The fourth type is made up primarily of calcium and is usually found in patients with hypercalcemia.
  • When multiple gallstones or a singular large gallstone get impacted in Hartman’s pouch (the lower outpouching of the gallbladder), external compression of the common bile duct or the common hepatic duct can occur.
  • The exact mechanism as to why this occurs is unknown but appears to be related to a floppy Hartman’s pouch containing a higher mass of stones, such as with multiple stones or a single large impacted stone. This causes subsequent inflammation of the area, which can also lead to fistula formation over time.

Symptoms of Mirizzi syndrome

Mirizzi’s syndrome could be asymptomatic or non-specific. Common symptoms include:

  • Constitutional symptoms including fever, nausea, vomiting, diarrhea and constipation
  • Jaundice
  • Right upper quadrant abdominal pain
  • Symptoms of recurrent cholangitis
  • Rarely, may present with symptoms of gallstone ileus


The most common complication of Mirizzi syndrome is cholecystobiliary or cholecysto-enteric fistula formation due to prolonged inflammation. Surgical complications with prolonged procedure time due to dense adhesions may also occur. These include bile duct injury and hemorrhage. Massive hemorrhage during dissection of the Calot triangle can occur in complex cases. Other complications of prolonged inflammation that can be seen in patients with Mirizzi syndrome include:

  • Cutaneous fistula formation
  • Secondary biliary cirrhosis
  • Delayed onset biliary strictures

Diagnosis and test

Ultrasonography is a diagnostic imaging technique that uses sound waves to examine the internal organs in the body.

MRCP uses magnetic resonance imaging to view pancreatic and biliary ducts non-invasively and define the lesion before a surgery.

ERCP is used occasionally when it is required to relieve cholangitis with the help of an endoscopic stent when ultrasound is erroneous.

CT scan uses computer processed images to virtually view specific areas of the body.

Treatment and medications

Stent placement during ERCP may be temporary option prior to surgery but is not definitive therapy

  • May obviate need for CBD exploration at surgery

Definitive treatment is surgical, with approach determined by type of Mirizzi syndrome

Type I: Partial or total cholecystectomy without CBD exploration

  • Although laparoscopic resection is theoretically possible, high rate of conversion to open cholecystectomy

Type II: Subtotal cholecystectomy, surgical repair of fistula (suture repair, choledochoplasty), and exploration of CBD

Type III: Subtotal cholecystectomy or biliary reconstruction with biliary-enteric anastomosis

Type IV: Biliary reconstruction, usually Roux-en-Y hepaticojejunostomy

Mastitis is an infection and inflammation of the breast, usually the fatty tissue of the breast.


Mastitis is an infection and inflammation of the breast, usually the fatty tissue of the breast, that causes redness, pain and swelling. As this swelling pushes on the milk ducts, it causes pain. Mastitis is usually caused by an infection with the bacteria Staphylococcus aureus. These bacteria are normally present on your skin, but cause problems when they enter the body. Bacteria causing mastitis enter through a break or crack in the skin of the breast, usually on the nipple. In fact, mastitis usually occurs in women who are breastfeeding because the nipples often become dry and irritated and can become cracked during nursing. This allows the bacteria to invade breast tissue, in particular the milk ducts and milk glands.

Mastitis in a nonbreast feeding woman is more common after menopause than before. In very rare cases, this may indicate the presence of another primary disease, such as breast cancer. At the same time, a clogged milk duct can mimic mastitis. While a woman adjusts to breastfeeding a new infant, the milk ducts inside the breast can become clogged, causing tenderness, redness, lumps and even heat under the skin surface, but without infection.

It is possible in many cases to determine yourself if you have a clogged milk duct as opposed to mastitis. You can usually relieve a clogged milk duct by massaging the area. If these symptoms persist, however, or if you develop fever and muscle pains or body aches, it is more likely that you have indeed developed mastitis. Fortunately, mastitis can be easily treated.

While mastitis is almost never an emergency, left untreated it can lead to a breast abscess, which is a collection of pus in a hollow area in the breast. Your doctor may need to drain the abscess. A wiser course is to never let mastitis lead to an abscess.

Types of Mastitis

The different types of mastitis include:

Lactation: This infection type affects breastfeeding women. Also called puerperal mastitis, it’s the most common.

Periductal: Menopausal and postmenopausal women and smokers are more prone to periductal mastitis. Also called mammary duct ectasia, this condition occurs when milk ducts thicken. The nipple on the affected breast may turn inward (inverted nipple) and produce a milky discharge.

Mastitis Risk factors

Risk factors for mastitis include:

  • Previous bout of mastitis while breast-feeding
  • Sore or cracked nipples although mastitis can develop without broken skin
  • Wearing a tightfitting bra or putting pressure on your breast when using a seat belt or carrying a heavy bag, which may restrict milk flow
  • Improper nursing technique
  • Becoming overly tired or stressed
  • Poor nutrition
  • Smoking

Causes of Mastitis

These are some of the risk factors that might increase your chance of developing the mastitis infection:

  • Incorrect breastfeeding technique: If you don’t vary your breastfeeding positions or don’t fully empty each breast, for example, the milk can build up and can become trapped in the milk ducts.
  • Clogged milk ducts that aren’t cleared in time: If a milk duct gets clogged with milk, a hard and tender lump will form. If the clogged duct isn’t cleared, an infection can set in.
  • A crack or blister on the nipple: A crack in the skin of the nipple or a milk blister can lead to a bacterial infection in the breast. A milk blister is a painful white spot on or near the nipple. It isn’t the same as a blister caused by friction from an incorrect latch from your baby while feeding; it’s a spot of thickened milk near the opening of the nipple that may block the flow of milk.
  • Constraining your breasts: Wearing a bra that is too tight or putting pressure on your breast (for example, from the strap of a heavy bag) can restrict the flow of milk.
  • A weakened immune system: Being overly stressed or fatigued, or having poor nutrition can suppress your immune system and make you more susceptible to the mastitis infection.
  • Previous bouts of mastitis.


Women who have mastitis may feel ill. They may feel run down or achy. In addition to an inflamed breast, they may feel like they have the flu. Other symptoms may include:

  • Breast pain
  • Swelling
  • A tender, red, wedge-shaped area on the breast
  • A breast that is warm or hot to the touch
  • A burning sensation while breastfeeding
  • Discharge from the nipple
  • Fever
  • Chills
  • Nausea or vomiting

Mastitis usually affects only one breast at a time.

Mastitis complications

If your symptoms do not get better within 24 to 48 hours, it’s important to contact your doctor. A delay in treatment can lead to complications such as early weaning, breast abscess, or thrush.

Early Weaning

The development of mastitis may cause some women to consider weaning. Nursing with mastitis is safe, and it helps to clear the infection, so it’s not necessary to stop breastfeeding. In fact, the sudden end of breastfeeding can make mastitis worse, and it’s more likely to lead to an abscess.8

Breast Abscess

An abscess is a tender, fluid-filled lump that can form in your breast as a result of mastitis. If you develop an abscess, your doctor may need to remove the fluid with a needle, or you may have to have minor surgery.


Thrush is a fungal or yeast infection. Yeast is naturally present on and in our bodies, but when it overgrows or moves to a place it shouldn’t be, it can become a problem. Thrush can cause a breast infection by getting into the breast through damaged nipples, but it can also develop as a result of mastitis.

The use of antibiotics to treat mastitis can lead to an overgrowth of yeast. When this happens, you can develop a yeast infection that causes red, burning nipples and breast pain. You also may see white patches or redness in your baby’s mouth.

If you see thrush on your nipples or in your child’s mouth, call the doctor. Both you and your child will need treatment with an anti-fungal medication. And, because yeast spreads quickly and is difficult to get rid of, it’s possible that other family members may need to be treated as well.

Diagnosis and test

If you think you have mastitis, notify your doctor as soon as possible. Your doctor will examine your breasts and come up with a treatment plan.

Most of the time, mastitis is diagnosed with an examination and additional tests are not needed. However, if the mastitis doesn’t clear up or continues to get worse, your doctor may order the following tests.

  • Breastmilk culture: If your infection is severe, occurred in the hospital, or isn’t responding to antibiotics, your doctor may order a culture.
  • Ultrasound: Sometimes doctors will order an ultrasound if your condition doesn’t improve within 48 to 72 hours.
  • Blood cultures: If your breast redness continues to worsen and your vital signs become unstable, the doctor may order a blood culture.

Treatment and medications

The process of treating lactation mastitis often includes:

  • Antibiotics: A prescription of 10 to 15day course of antibiotic is recommended for the treatment of lactation mastitis. It can take a short span of only 24 hour of antibiotic usage for you to feel well once again. In order to minimize the risk of lactation mastitis recurring, it is advisable to finish all the prescribed bills.
  • Pain relievers: A mild reliever of pain can be recommended by a doctor. Ibuprofen (Motrin IB, Advil and others) and acetaminophen (Tylenol and others) are examples of the mild pain killers.
  • You should adjust with you nursing technique: Ensure that your child is able to feed in the right manner and also you must confirm that the milk in your breast is fully emptied. If you need any support your doctor can refer you to a lactating consultant. The physician can also consider to reviews the technique that you apply when breast-feeding.
  • You should promote your body to fight the infection by drinking a lot of fluids. This process is known as self-care. You ensure that you continue breast feeding and get enough rest.

It is very important to go back to the doctor if the lactation mastitis has not cleared.

How to treat mastitis naturally

Rest is one of the best things you can do while your body is fighting an infection is to rest. So snuggle up in bed with your little one and recruit help if needed.

Nurse: Though breast is tender and nursing may be painful, but it’s important to empty out the infected breast thoroughly. Nurse and pump as often as possible. But of course, continue nursing on the other side too.

Massage: It might be painful, but try to massage the breast toward the nipple while nursing and in between feedings. This will help loosen the milk duct.

Apply heat: Warmth increases circulation and helps the milk to flow. Apply a warm compress on the infected area for 15 minutes, three times a day, followed by a massage. Or, massage the infected breast in a warm shower.

Drink water: Staying hydrated is important for maintaining your milk supply.

Prevention of Mastitis

To help prevent mastitis:

  • Mothers and midwives should thoroughly wash their hands before touching the breasts after a nappy change.
  • Make sure the baby is positioned and attached properly on the breast to assist in thorough breastmilk drainage.
  • Avoid long periods between feeds. Feed frequently. Avoid skipping feeds, if replacing a breastfeed with a bottle, express to avoid blocked milk ducts or a reduction in your breastmilk supply.
  • Wear loose, comfortable clothing. Bras, if worn, should be properly fitted.
  • Avoid nipple creams, ointments and prolonged use of nipple pads.
  • If the mother has been unwell, see a GP to rule out anaemia.

Thailand Prime Minister to visit Saudi King.

It was gathered that the Thailand’s Prime minister will visit Saudi Arabia in what will be the first high-level meeting between the two countries since a diplomatic row over a jewellery theft nearly three decades ago, the Saudi foreign ministry said in a statement on Sunday (Jan 23),

Saudi Arabia downgraded its diplomatic relations with Bangkok following the theft in 1989 of around US$20 million of jewels by a Thai janitor working in the palace of a Saudi prince, in what became known as the “Blue Diamond Affair.

A large number of the gems, including the rare blue diamond, are yet to be recovered.

Thailand’s Premier Prayuth Chan-ocha will start a two-day visit to Saudi Arabia on Tuesday at the invitation of Saudi Crown Prince Mohammed bin Salman, the Saudi ministry said.

The visit comes amid consultations that led to bringing views closer on issues of common interest,” the ministry said.

The visit is aimed at coordinating on those issues, it said, without elaborating.

The theft of the jewels remains one of Thailand’s biggest unsolved mysteries and was followed by a bloody trail of destruction that saw some of Thailand’s top police generals implicated.

A year after the theft, three Saudi diplomats in Thailand were killed in three separate assassinations in a single night.

A month later, a Saudi businessman, Mohammad al-Ruwaili, who witnessed one of the shootings, disappeared and later in 2014, a Thai criminal court dismissed a case against five men, including a senior police officer, charged with murdering Ruwaili over the precious stones.

Thailand has been eager to normalise ties with the oil-rich Kingdom after the spat that has cost billions of dollars in two-way trade and tourism revenues and the loss of jobs to tens of thousands of Thai migrant workers.

Fulani herdsmen allegedly invade a mining site and brutally murdered four person and shot a woman.

According to a report it was gathered that no fewer than four persons were brutally murdered on Saturday night by gunmen suspected to be Fulani herdsmen at Dong village in Jos North Local Government Area of Plateau State.

It was reported that the attack took place at a mining site in the community, leaving four persons death and a woman survived with gunshots injuries.

Police Public Relations Officer (PPRO), ASP Ubah Gabriel Ogaba confirmed the incident and said four persons were attack during mining and killed.

He said the Police has commenced investigation into the killings with a view to bring the perpetrators to book.

Four people were attack and kill on Saturday during mining in Dong community in Jos North. Investigation has commenced to identify and arrest those who launched the attack.

He urged residents of the community to remained calm and law abiding as the Police is working to uncover the suspects.

Chairman Arewa Consultative Forum (ACF), Plateau State Henry Jadike condemned the incident and called on security to arrest the perpetrators.

He expressed his sincere condolences to the bereaved family and urged them to take solace in God.

It is with deepest sense of regret that we sent our condolences to the Dong Community, Acting District Head and its Cabinet. We sympathize with you and your entire community for the lost.

Giardiasis (giardia) is an intestinal infection marked by abdominal cramps.


Giardiasis (giardia) is an intestinal infection marked by abdominal cramps, bloating, nausea, and bouts of watery diarrhea. Giardia infection is caused by Giardia lamblia a microscopic parasite that is found worldwide, especially in areas with poor sanitation and unsafe water. Infection with giardiasis is one of the most common causes of waterborne disease in the USA. The parasites are found in streams and lakes in the backcountry but also in municipal water supplies, pools, whirlpool spas, and wells. Infection with giardia may be transmitted through food and contact person to person.

Infections of the Giardia typically clear up within weeks. But you may have bowel problems long after the parasites have gone away. Several drugs are generally effective against parasites of giardia but not all respond to them. Prevention is the best defense for you.

Life cycle

The parasite has a direct life cycle. It lives in the lower small intestine of the cat in its trophozoite form, adherent to the intestinal wall. It replicates by binary fission to produce the encysted form, which is passed in the feces in addition to the trophozoites.

Life cycle of Giardia lamblia

Spread of Giardiasis

Giardiasis can be spread by:

  • Swallowing Giardia picked up from surfaces (such as bathroom handles, changing tables, diaper pails, or toys) that contain feces (poop) from an infected person or animal
  • Drinking water or using ice made from water sources where Giardia may live (for example, untreated or improperly treated water from lakes, streams, or wells)
  • Swallowing water while swimming or playing in the water where Giardia may live, especially in lakes, rivers, springs, ponds, and streams
  • Eating uncooked food that contains Giardia organisms
  • Having contact with someone who is ill with giardiasis
  • Traveling to countries where giardiasis is common

Anything that comes into contact with feces (poop) from infected humans or animals can become contaminated with the Giardia parasite. People become infected when they swallow the parasite. It is not possible to become infected through contact with blood.


Giardia has a worldwide distribution, occurring in both temperate and tropical regions. It continues to be the most frequently identified human protozoal enteropathogen. Prevalence rates vary from 4-42%. In the industrialized world, overall prevalence rates are 2-5%. In the developing world, G intestinalis infects infants early in life and is a major cause of epidemic childhood diarrhea. Prevalence rates of 15-20% in children younger than 10 years are common.

Giardia is the most common gut parasite in the United Kingdom, and infection rates are especially high in Eastern Europe. Prevalence rates of 0.94-4.66% and 2.41-10.99% have been reported in Italy.

Giardiasis risk factors

Giardiasis is more common in places with poor water or sewage treatment. Asia and South America have the highest infection rates. Risk is also higher for people who:

  • Live in crowded places with poor sanitation
  • Drink untreated water
  • Have low stomach acid
  • Take stomach acid reducers
  • Have oral to anal contact during sex
  • Have a weakened immune system
  • Are a daycare worker or work in a group setting
  • Swim in water sources that may be contaminated

Causes of Giardiasis

The parasite that causes giardiasis lives in 2 stages:

  • Trophozoites (the active form inside the body)
  • Cysts (the resting stage that enables the parasite to survive outside the body)

The infection starts when the cysts are taken in through contaminated food or water. Stomach acid activates the cysts and the trophozoites are released. They attach to the lining of the small intestine and reproduce. Cysts form in the lower intestines. They are then passed in the feces.

The parasite may be passed from person-to-person by contact with infected feces, or through consuming contaminated food or water.


More than two-thirds of people who are infected may have no signs or symptoms of illness, even though the parasite is living in their intestines. When the parasite does cause symptoms, the illness usually begins with severe watery diarrhea, without blood or mucus. Giardiasis affects the body’s ability to absorb fats from the diet, so diarrhea contains unabsorbed fats. That means that the diarrhea floats is shiny, and smells very bad.

Other symptoms include:

  • Abdominal cramps
  • Large amounts of intestinal gas
  • An enlarged belly from the gas
  • Loss of appetite
  • Nausea and vomiting
  • Sometimes a low-grade fever

These symptoms may last for 5 to 7 days or longer. If they last longer, a child may lose weight or show other signs of poor nutrition.

Sometimes, after acute (or short-term) symptoms of giardiasis pass, the disease begins a chronic (or more prolonged) phase. Symptoms of chronic giardiasis include:

  • Periods of intestinal gas
  • Abdominal pain in the area above the navel (belly button)
  • Poorly formed, “mushy” bowel movements (poop)


These complications can occur:

  • Dehydration (loss of water and other fluids in the body)
  • Malabsorption (inadequate absorption of nutrients from the intestinal tract)
  • Weight loss

Diagnosis and test

Giardia infection can be challenging to diagnose; Health care providers rely on a stool analysis to confirm the presence of the parasite.

Stool Analysis

Checking your stool for the parasite is the primary way doctors diagnose a Giardia infection. The test can be done in one of two ways, both of which will require you to provide a stool sample.

Stool Ova and Parasites Exam: For this exam, a small amount of stool is smeared on a slide. The sample is examined with a microscope for signs of cysts or adult parasites.

Antigen Test: An antigen test doesn’t look for the whole parasite—rather, it looks for a protein made by Giardia when it’s in the human body.11 These proteins are what the immune system responds to when it’s trying to defend itself from the infection.

Giardia parasites can be hard to spot and don’t always show up in a stool sample from someone who is infected. If your doctor suspects you have giardiasis, they might order both tests at the same time. Or, if the first test comes back negative, they might have you give additional stool samples especially if your symptoms match up with giardiasis.

String Test

If stool tests don’t confirm the diagnosis but your doctor still suspects giardiasis, they might use another tool called the string test or Entero-test.

  • For the test, you swallow a string with a weighted gelatin capsule attached to one end. As the string moves through the digestive tract, it collects samples from the upper part of the small intestine. About four hours later, your doctor removes the string and examins the fluids it gathered under a microscope for the parasite.
  • The string test is not typically the first test your doctor will use if they think you have giardiasis. Some researchers believe the string test is better at spotting Giardia than stool tests, but other studies claim it isn’t effective.
  • Since the research has been inconsistent and the test can be uncomfortable for patients, it’s typically only used when stool tests are negative but giardiasis is highly suspected.

Treatment and medications

Children and adults who have giardia infection without symptoms usually don’t need treatment unless they’re likely to spread the parasites. Many people who do have problems often get better on their own in a few weeks.

When signs and symptoms are severe or the infection persists, doctors usually treat giardiasis with medications such as:

Metronidazole (Flagyl): Metronidazole is the most commonly used antibiotic for giardia infection. Side effects may include nausea and a metallic taste in the mouth. Don’t drink alcohol while taking this medication.

Tinidazole (Tindamax): Tinidazole works as well as metronidazole and has many of the same side effects, but it can be given in a single dose.

Nitazoxanide (Alinia): Because it comes in a liquid form, nitazoxanide may be easier for children to swallow. Side effects may include nausea, flatulence, yellow eyes, and brightly colored yellow urine.

There are no consistently recommended medications for giardiasis in pregnancy because of the potential for adverse drug effects on the baby. If your symptoms are mild, your doctor may recommend delaying treatment until after the first trimester. If treatment is necessary, discuss the best available treatment option with your doctor.

Prevention of Giardiasis

To help prevent the spread of giardia:

  • Keep infected people from going to childcare, pre-school, school or work until they have not had any diarrhoea for at least 24 hours
  • Do not use swimming pools for at least 2 weeks after diarrhoea has completely stopped
  • Wash hands properly, especially after going to the toilet and before handling food
  • Do not share linen, towels or eating utensils with others while there are symptoms
  • Boil any water before drinking if you suspect it may be contaminated
  • Treating infected people reduces the spread of the parasite.

Heartburn is a sensation of burning in the chest caused by stomach acid backing up into the esophagus (food pipe).


Heartburn is a sensation of burning in the chest caused by stomach acid backing up into the esophagus (food pipe). The burning is usually in the central part of the chest, just behind the sternum (breast bone). The burning can worsen or can be brought on by lying flat or on the right side. Pregnancy tends to aggravate heartburn.

Many people experience heartburn and there are a large number of over-the-counter (OTC) medications and home remedies available to treat heartburn. In most cases you will not need to see a health-care professional, except if the symptoms are frequent (several times a week), severe or increasing in severity. If heartburn is severe or the pain is accompanied with additional symptoms such as shortness of breath, radiation into your arms or neck, you will need to see a doctor to distinguish these symptoms from more serious medical conditions such as a heart attack.

GERD (Gastroesophageal reflux disease) can be considered a chronic and more serious form of reflux with heartburn as the major symptom; however, there may be other symptoms or no symptoms at all. If your heartburn symptoms occur more than twice a week you should see your health-care professional to make sure no serious problems are present.

Risk factors

Risk Factors for heartburn and GERD Include:

  • Dietary choices- acidic or fatty meals, caffeine, eating close to bedtime, and large meals
  • Hiatal hernia (a condition in which part of the stomach moves above the diaphragm, which is the muscle that separates the chest and abdominal cavities)
  • Obesity
  • Pregnancy
  • Scleroderma
  • Smoking or alcohol use

Causes of Heartburn

Heartburn occurs when food and stomach juices back up (reflux) into the esophagus, which is the tube that leads from the throat to the stomach. This process is called gastroesophageal reflux. Common causes of reflux include:

  • Incomplete closing of the valve (the lower esophageal sphincter, or LES) between the esophagus and the stomach.
  • Foods and drinks, such as chocolate, peppermint, fried foods, fatty foods, sugars, coffee, carbonated drinks, and alcohol. After heartburn occurs, the backflow of stomach juices can cause the esophagus to become sensitive to other foods, such as citrus fruits, tomatoes, spicy foods, garlic, and onions. Eating these foods may cause more heartburn.
  • Pressure on the stomach caused by obesity, frequent bending over and lifting, tight clothes, straining with bowel movements, vigorous exercise, and pregnancy.
  • Smoking and use of other tobacco products.
  • Prescription and nonprescription medicines, such as aspirin, ibuprofen, prednisone, iron, potassium, antihistamines, and sleeping pills.
  • A hiatal hernia, which occurs when a small portion of the stomach pushes upward through the diaphragm, which is the muscle that separates the lungs from the abdomen.
  • Stress, which can increase the amount of acid your stomach makes and cause your stomach to empty more slowly.

Symptoms of Heartburn

Heartburn is caused by the backward movement of stomach contents into the esophagus, which may result in a number of symptoms. The symptoms can vary in intensity among individuals.

Common symptoms of heartburn

You may experience heartburn symptoms daily or just once in a while. At times any of these common symptoms can be severe:

  • Abdominal burning
  • Abdominal pain
  • Burning feeling in the upper chest
  • Indigestion
  • Pain in the upper chest

In some cases, symptoms of heartburn can be a sign of a heart attack or other serious condition. Seek immediate medical care if you, or someone you are with, have any of these life-threatening symptoms including:

  • Chest pain, chest tightness, chest pressure, palpitations
  • Heartburn symptoms that persist despite use of usual remedies
  • Radiating pain down your shoulder and arm
  • Respiratory or breathing problems such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, or choking
  • Vomiting blood or black material (resembling coffee grounds)

Heartburn complications

If the afore-mentioned distinct attributes of heartburn gradually disappear within a day or two, there is no cause for concern.

Underlying Serious Ailments:

In some circumstances, the affected person displays difficulty in breathing, with excruciating chest pain, inability to swallow, constant nausea or vomiting, sudden weight loss and numerous recurring episodes of heartburn within a week. It is then advised to consult a doctor at once, to identify the trigger behind these symptoms.

GERD (Gastroesophageal Reflux Disease):

Incessant heartburn that takes place more than twice a week progresses onto GERD. This sickness requires prescription drugs and sometimes even surgery, to mend the injured oesophagus, restore its routine functioning and prevent precancerous alterations called Barrett’s oesophagus, from developing in the body.

Diagnosis and test

If your heartburn goes on for a long time, it may be a sign of a more serious condition known as gastroesophageal reflux disease (GERD). Your doctor may be able to tell if GERD is the cause of your heartburn from your symptoms. But to tell how serious it is, they may do several tests, including:

X-ray: You’ll drink a solution called a barium suspension that coats the lining of your upper GI (gastrointestinal) tract — your esophagus, stomach, and upper small intestine. This coating lets doctors see defects that could mean a problem in your digestive system.

Endoscopy: A small camera on a flexible tube is put down your throat to give a view of your upper GI tract.

Ambulatory acid probe test (esophageal pH monitoring): An acid monitor is put into your esophagus and connected to a small computer that you can wear on a belt or shoulder strap. It measures when stomach acid backs up into your esophagus and for how long.

Esophageal motility testing (esophageal manometry): A catheter is put into your esophagus and measures pressure and movement.

Treatment and medications

Non-Surgical Treatment for Heartburn

Most people can manage the discomfort of heartburn with lifestyle changes, weight loss and medications, including Proton Pump Inhibitors, or PPIs. PPIs reduce the amount of stomach acid made by glands in the lining of the stomach. They include over-the-counter medications, as well as omeprazole. While common, these medications are not without risk. Short-term use can result in headache, diarrhea, constipation and abdominal pain. Recent studies point to long-term effects, such as increased risk of pneumonia and bone fractures.

Surgical Treatment for Heartburn

Sometimes a surgical approach may be necessary to alleviate symptoms. If surgery is required, Summa Health patients have access to the latest technology and surgical techniques. Surgical options include:

Laparoscopic Nissen Fundoplication

During Nissen fundoplication, the surgeon wraps the top of the stomach around the lower esophagus. This reinforces the lower esophageal muscle or sphincter, making it less likely that acid will back up into the esophagus. The procedure typically lasts up to one and a half hours. Patients are started on clear liquids the next morning and discharged in the afternoon.

LINX® Reflux Management System

LINX is a small flexible ring of magnets that opens to allow food and liquid down, then closes to prevent stomach contents from moving up. Unlike other procedures, LINX requires no alteration to the stomach, reduces gas and bloating and preserves the ability to belch and vomit. While designed to be a lifelong treatment, LINX can be removed using a minimally invasive procedure that generally lasts less than an hour. Moreover, it doesn’t limit your future treatment options.

Several over-the-counter medications can treat heartburn, including:

  • Antacids- Antacids may provide fast relief by neutralizing stomach acid. They do not, however, heal a damaged esophagus or treat any underlying causes of heartburn.
  • H-2-receptor antagonists (H2RAs)- These medications also reduce stomach acid, but do not provide relief as quickly as antacids. They can, however, provide relief for a longer amount of time.
  • Proton pump inhibitors such as Prevacid 24HR, Nexium 24HR, and Prilosec OTC can reduce stomach acid as well.

In rare cases, surgery may be considered when all other treatments have failed to reduce symptoms.

Prevention of Heartburn

The following lifestyle changes can help you to avoid heartburn:

Lose weight/maintain a healthy weight – Excess weight places pressure on the stomach causing stomach acid to back up into the oesophagus

Quit smoking – Smoking impairs the normal functioning of the oesophageal sphincter

Diet control – Avoid foods that trigger your heartburn and reduce the amount of food you eat

Avoid lying down after a meal – Wait at least three hours after eating before lying down or going to bed

Raise the head of your bed by placing blocks under the feet at the head of your bed or insert a wedge between your mattress and the bed’s base so that your body is elevated from the waist up.

Apraxia is a poorly understood neurological condition.

What Is Apraxia?

Apraxia is a poorly understood neurological condition. People who have it find it difficult or impossible to make certain motor movements, even though their muscles are normal. Milder forms of apraxia are known as dyspraxia.

Apraxia can occur in a number of different forms. One form is orofacial apraxia. People with orofacial apraxia are unable to voluntarily perform certain movements involving facial muscles. For instance, they may not be able to lick their lips or wink. Another form of apraxia affects a person’s ability to intentionally move arms and legs.

With apraxia of speech, a person finds it difficult or impossible to move his or her mouth and tongue to speak. This happens, even though the person has the desire to speak and the mouth and tongue muscles are physically able to form words.


Different types of apraxia affect the body in slightly different ways:

Limb-kinetic apraxia

People with limb-kinetic apraxia are unable to use a finger, arm, or leg to make precise and coordinated movements. Although people with limb-kinetic apraxia may understand how to use a tool, such as a screwdriver, and may have used it in the past, they are now unable to carry out the same movement.

Ideomotor apraxia

People with ideomotor apraxia are unable to follow a verbal command to copy the movements of others or follow suggestions for movements.

Conceptual apraxia

This form of apraxia is similar to ideomotor apraxia. People with conceptual apraxia are also unable to perform tasks that involve more than one step.

Ideational apraxia

People with ideational apraxia are unable to plan a particular movement. They may find it hard to follow a sequence of movements, such as getting dressed or bathing.

Buccofacial apraxia

People with buccofacial apraxia, or facial-oral apraxia, are unable to make movements with the face and lips on command.

Constructional apraxia

People with constructional apraxia are unable to copy, draw, or construct basic diagrams or figures.

Oculomotor apraxia

Oculomotor apraxia affects the eyes. People with this type of apraxia have difficulty making eye movements on command.

Verbal apraxia

People with verbal or oral apraxia find it challenging to make the movements necessary for speech. They may have problems producing sounds and understanding rhythms of speech.


Apraxia is caused by damage to the brain. When apraxia develops in a person who was previously able to perform the tasks or abilities, it is called acquired apraxia.

The most common causes of acquired apraxia are:

  • Brain tumor
  • The condition that causes gradual worsening of the brain and nervous system (neurodegenerative illness)
  • Dementia
  • Stroke
  • Traumatic brain injury

Apraxia may also be seen at birth. Symptoms appear as the child grows and develops. The cause is unknown.

Apraxia of speech is often present along with another speech disorder called aphasia. Depending on the cause of apraxia, a number of other brain or nervous system problems may be present.

Risk Factors

Apraxia may be due to stroke. Stroke is more common in older adults.

Factors that may increase your risk of stroke include:

  • Prior stroke or cardiovascular disease
  • Prior transient ischemic attack (TIA)
  • High blood pressure
  • High cholesterol
  • Diabetes
  • Smoking
  • Dialysis treatment, which takes over the job of the kidneys when they fail


A person with apraxia is unable to put together the correct muscle movements. At times, a completely different word or action is used than the one the person intended to speak or make. The person is often aware of the mistake.

Symptoms include:

  • Distorted, repeated, or left out speech sounds or words. The person has difficulty putting words together in the correct order.
  • Struggling to pronounce the right word
  • More difficulty using longer words, either all the time or sometimes
  • Ability to use short, everyday phrases or sayings (such as “How are you?”) without a problem
  • Better writing ability than speaking ability

Other forms of apraxia include:

  • Buccofacial or orofacial apraxia. Inability to carry out movements of the face on demand, such as licking the lips, sticking out the tongue, or whistling.
  • Ideational apraxia. Inability to carry out learned, complex tasks in the proper order, such as putting on socks before putting on shoes.
  • Ideomotor apraxia. Inability to voluntarily perform a learned task when given the necessary objects. For instance, if given a screwdriver, the person may try to write with it as if it were a pen.
  • Limb-kinetic apraxia. Difficulty making precise movements with an arm or leg. It becomes impossible to button a shirt or tie a shoe.

Possible Complications

Having apraxia may lead to:

  • Learning problems
  • Low self-esteem
  • Social problems

Diagnosis and tests

To diagnose apraxia, a doctor will look at a person’s full medical history and consider all of their symptoms to identify any underlying causes. They may also be looking to rule out similar conditions, such as motor weakness, aphasia, or dyspraxia.

A doctor may carry out a variety of tests to assess:

  • Verbal and nonverbal communication
  • How people participate and function in certain activities
  • Coordination
  • Hearing and listening abilities

Tests may include both physical tests to measure motor coordination skills and language tests to check the ability to understand commands.

Tests may include:

Hearing tests. Your doctor may order hearing tests to determine if hearing problems could be contributing to your child’s speech problems.

Oral-motor assessment. Your child’s speech-language pathologist will examine your child’s lips, tongue, jaw, and palate for structural problems, such as tongue-tie or a cleft palate, or other problems, such as low muscle tone. Low muscle tone usually isn’t associated with CAS, but it may be a sign of other conditions.

Your child’s speech-language pathologist will observe how your child moves his or her lips, tongue and jaw in activities such as blowing, smiling and kissing.

Speech evaluation. Your child’s ability to make sounds, words and sentences will be observed during play or other activities.

Your child may be asked to name pictures to see if he or she has difficulty making specific sounds or speaking certain words or syllables.


People with apraxia can benefit from treatment by a health care team. The team should also include family members.

Occupational and speech therapists play an important role in helping both people with apraxia and their caregivers learn ways to deal with the disorder.

During treatment, therapists will focus on:

  • Repeating sounds over and over to teach mouth movements
  • Slowing down the person’s speech
  • Teaching different techniques to help with communication

Recognition and treatment of depression are important for people with apraxia.

To help with communication, family and friends should:

  • Avoid giving complex directions.
  • Use simple phrases to avoid misunderstandings.
  • Speak in a normal tone of voice. Speech apraxia is not a hearing problem.
  • DO NOT assume that the person understands.
  • Provide communication aids, if possible, depending on the person and condition.

Other tips for daily living include:

  • Maintain a relaxed, calm environment.
  • Take time to show someone with apraxia how to do a task, and allow enough time for them to do so. DO NOT ask them to repeat the task if they are clearly struggling with it and doing so will increase frustration.
  • Suggest other ways to do the same things. For example, buy shoes with a hook and loop closure instead of laces.

If depression or frustration is severe, mental health counseling may help.


The prognosis for individuals with apraxia varies. With therapy, some patients improve significantly, while others may show very little improvement. Some individuals may benefit from the use of a communication aid. However, many people with apraxia are no longer able to be independent. Those with limb-kinetic and/or gait apraxia should avoid activities in which they might injure themselves or others.

Occupational therapy, physical therapy, and play therapy may be considered as other references to support patients with apraxia. These team members could work along with the SLP to provide the best therapy for people with apraxia. However, because people with limb apraxia may have trouble directing their motor movements, occupational therapy for stroke or other brain injuries can be difficult.

No medication has been shown useful for treating apraxia.

Acne vulgaris is an inflammatory disorder of the pilosebaceous unit, which runs a chronic course and it is self-limiting.

What is Acne vulgaris?

Acne vulgaris is an inflammatory disorder of the pilosebaceous unit, which runs a chronic course and it is self-limiting. Acne vulgaris is triggered by Propionibacterium acne in adolescence, under the influence of normal circulating dehydroepiandrosterone (DHEA). It is a very common skin disorder which can present with inflammatory and non-inflammatory lesions chiefly on the face but can also occur on the upper arms, trunk, and back.

Acne vulgaris


Acne may appear in adolescence, and it persists through the early thirties. Acne is more common in males than in females. Urban populations are more affected than rural populations. About 20% of the affected individuals develop severe acne which results in scarring. Some races appear to be more affected than others. Asians and Africans tend to develop severe acne, but mild acne is more common in the white population. In general, populations with darker skin also tend to develop hyperpigmentation. Acne can also develop in neonates but in most cases resolves spontaneously.

Types of acne vulgaris

Four main types are recognized:

Pyoderma faciale is seen usually in an older woman with existing acne who is subjected to stress when a localized but explosive pattern of the disease appears.

Acne conglobata is a severe form of the disease which affects the face, back, and limbs. Cystic and pustular lesions occur and scarring may be marked. It occurs mainly in men.

Acne fulminans is an immunologically induced severe systemic variant of acne conglobata. The clinical features are those of acne conglobata plus the classic delayed hypersensitivity systemic reaction with splenomegaly, arthropathy, and rashes.

Gram-negative folliculitis is associated with the long-term antibiotic treatment of acne. Acne which was well controlled suddenly appears to “escape” from control. This condition takes the form of a sudden eruption of small follicular pustules.

Acne vulgaris risk factors

Risk factors increase with:

  • Exposure to extremely hot or cold temperatures
  • Stress
  • Oily skin
  • Endocrine disorders
  • Use of drugs, such as cortisone, male hormones, or oral contraceptives
  • Family history of acne
  • Some cosmetics

Acne vulgaris pathogenesis

Acne vulgaris is a multifactorial condition that ultimately results in inflammatory changes of the pilosebaceous unit.

  • Although no specific genetic factor has been correlated with acne vulgaris, epidemiologic studies have demonstrated a family history of acne is associated with increased incidence.
  • Diet has traditionally been associated with a causal or influential factor in acne vulgaris, but this remains controversial. However, recent data is suggestive of an association with a high glycemic index diet.

The instigating step in an acne lesion is keratinocyte proliferation and adhesion

  • Androgen production controls this effect and simultaneously increases sebum production.
  • These changes create an obstruction of the pilosebaceous duct and the formation of a microcomedone.
  • In the setting of elevated androgens, sebum collection continues, and closed and open comedones appear.
  • Bacteria, in particular, Propionibacterium acnes, proliferate within this environment and contribute to local inflammation.
  • With worsening inflammatory mediators, the comedones progress to erythematous papules, pustules, cysts, and nodules.
  • In the setting of unremitting disease, the cysts and nodules can rupture, incite further inflammation, and create deep sinus tracts with severe scarring

Causes of Acne vulgaris

Hormones: At around 8 years of age, the adrenal glands start to produce androgens (male hormone) and the amount produced gradually increases during puberty. The sebaceous glands respond to androgens by producing more sebum and sometimes whiteheads (closed comedones) may develop in young children.

Sebaceous gland blockage: The skin cells lining the upper part of the hair follicle duct are not shed as normal but accumulate and form a plug (comedone).  The oil is trapped behind it.

Bacteria and inflammation: Increased numbers of acne bacteria (Propionibacterium acnes) accumulate in the duct and contribute to the inflammation that develops in the pimples.

Genetics: Hereditary factors contribute, however it is not known exactly how this works.

Stress: Adrenal glands produce more androgens when an individual is stressed. This can make acne worse.

Diet: Certain diets may contribute to the development of acne, however good scientific data is lacking.

Occupation: In rare cases, people working in certain industries may develop occupational acne where strict Work Health and Safety regulations have not been observed.

Symptoms of Acne vulgaris

  • Skin lesions and scarring can be a source of significant emotional distress. Nodules and cysts can be painful. Lesion types frequently coexist at different stages.
  • Comedones appear as whiteheads or blackheads. Whiteheads (closed comedones) are flesh-colored or whitish palpable lesions 1 to 3 mm in diameter; blackheads (open comedones) are similar in appearance but with a dark center.
  • Papules and pustules are red lesions 2 to 5 mm in diameter. Papules are relatively deep. Pustules are more superficial.
  • Nodules are larger, deeper, and more solid than papules. Such lesions resemble inflamed epidermoid cysts, although they lack true cystic structure.
  • Cysts are suppurative nodules. Rarely, cysts form deep abscesses. Long-term cystic acne can cause scarring that manifests as tiny and deep pits (icepick scars), larger pits, shallow depressions, or hypertrophic scarring or keloids.

Acne vulgaris symptoms

Acne vulgaris complications

  • Scars
  • Depression
  • Anxiety
  • Socially withdrawn
  • Poor facial aesthetics
  • Lack of self-esteem

Diagnosis and test 

A doctor or dermatologist will diagnose acne following a skin examination, taking note of where the acne is located and its severity. These factors are important in determining how the condition should be treated.

Professionals typically use a grading system to categorize acne:

Grade 1: Mild acne, probably limited to blackheads and whiteheads.

Grade 2: Moderate acne with papules and pustules, mostly confined to the face.

Grade 3: Moderately severe acne affecting the face, back and chest. Papules and pustules will be present, and inflamed nodules are possible.

Grade 4: Severe acne, with a large number of painful papules, pustules, and nodules.

Treatment and medications

Topical therapy

  • Topical retinoids like retinoic acid, adapalene, and tretinoin are used alone or with other topical antibiotics or benzoyl peroxide. Retinoic acid is the best comedolytic agent, available as 0.025%, 0.05%, 0.1% cream, and gel.
  • Topical clindamycin 1% to 2%, nadifloxacin 1%, and azithromycin 1% gel and lotion are available. Estrogen is used for Grade 2 to Grade 4 acne.
  • Topical benzoyl peroxide is now available in combination with adapalene which serves as comedolytic as well as antibiotic preparation. It is used as 2.5%, 4%,and 5% concentration in gel base.
  • Azelaic acid is antimicrobial and comedolytic available 15% or 20% gel. It can also be used in postinflammatory pigmentation of acne.
  • Beta hydroxy acids like salicylic acid are used as topical gel 2% or chemical peel from 10% to 20% for seborrhoea and comedonal acne, as well as, pigmentation after healing of acne.
  • Topical dapsone is used for both comedonal and papular acne, though there are some concerns with G6PD deficient individuals.

Before and after treatment

Systemic therapy

  • Doxycycline 100 mg twice a day as an antibiotic and anti-inflammatory drug as it affects free fatty acids secretion and thus controls inflammation.
  • Minocycline 50 mg and 100 mg capsules are used as once a day dose.
  • Other antibiotics such as amoxicillin, erythromycin and Bactrim are sometimes used, and if bacterial overgrowth or infection is masquerading as acne, other antibiotics such as ciprofloxacin may be used in pseudomonas related ‘acne.’
  • Isotretinoin is used as 0.5 mg/kg to 1 mg/kg body weight in daily or weekly pulse regimen. It controls sebum production, regulates pilosebaceous epidermal hyperproliferation, and reduces inflammation by controlling P. acnes. It may give rise to dryness, hairless, and cheilitis.
  • An oral contraceptive containing low dose estrogen 20 mcg along with cyproterone acetate as anti-androgens are used for severe recurrent acne.
  • Spironolactone (25 mg per day) can also be used in males. It decreases the production of androgens and blocks the actions of testosterone. If given to females, then pregnancy should be avoided because the drug can cause feminization of the fetus.
  • Scars are treated with submission, trichloroacetic acid, derma roller, micro needling, or fractional CO2 laser.

Prevention of Acne vulgaris

There are several ways to help prevent the development of acne. Not all preventive measures will work for all people, however, and no technique is guaranteed to be effective.

Techniques for helping to prevent acne include:

Keeping the face clean: The face should be cleaned roughly twice daily using warm water and mild soap in order to remove impurities and dead skin cells from the surface. Avoid washing the face too often, however, and do not use harsh soap or cleanser.

Moisturize: Moisturizing can help to keep the skin moist and prevent it from peeling. Products with “non-comedogenic” on the label should not block the pores and thus also not contribute to acne.

Diet and exercise: Eating a diet rich in fruits and vegetables, and low in fats and sugars may help to control acne. Similarly, getting plenty of exercises may also help to prevent acne outbreaks, as well as promoting general good health. After exercising, be sure to wash away any residual sweat, as this can contribute to acne.

Avoid makeup: Limiting makeup use may help to prevent an acne outbreak. Any makeup that is used should be oil-free and non-comedogenic.

Shampoo often: Wash the hair regularly with shampoo. If the hair is particularly oily, use shampoo daily.

Don’t touch: Avoid the temptation to touch the face throughout the day and be sure not to squeeze, pick or pop pimples; this will allow the acne to heal naturally.

Avoid excessive sunlight and tanning beds: Too much exposure to the sun and the use of tanning beds may damage the skin and is therefore not recommended.

Over-the-counter medication: Many anti-acne products are available over the counter from pharmacists and general stores. As well as controlling outbreaks after they have occurred, these products may help to prevent an outbreak from happening in the first place.