Febrile Conditions, Infections, and Communicable Diseases

I. Definition1. Fever – an elevation in body temperature above normal (98.6⁰F or 37⁰C) which may occur in response to

infection, inflammation, or unknown causes

2. Infection – a condition wherein the body is invaded by a disease-causing microorganisms or virus which grows and causes illness

3. Communicable or infectious disease – an illness caused by transmission of a specific infectious agent or its toxic products from an infected person or animal to a susceptible host, either

II. Etiology*exogenous agents such as bacteria or fungi or endogenous factors such as antigen-antibody reaction, malignancy, or graft rejection

III. Classification of Fever1. Acute – fevers are short in duration (less than 10 days); include influenza, pneumonia, tonsillitis, measles,

and other bacterial or viral infections2. Chronic – fevers last for weeks or months; the fever may be long-standing as in tuberculosis3. Intermittent (ex. Malaria)

IV. Metabolic Changes1. Increased metabolic rate

*7% for every 1⁰F or 13% for every 1⁰C rise in body temperature2. Increased protein catabolism

*this increases nitrogen wastes and renal load3. Decreased glycogen store and adipose tissue

*this results in weight loss4. Accelerated loss of body water and electrolytes (Na and K) through perspiration and polyuria5. Modified motility of GI tract which affects appetite, digestion, and absorption of nutrients

V. Diet

Diet Rationale1. High in calories (1.5 x basal energy

expenditure)Increased metabolism; restlessness also increases energy requirements

2. Protein increased (1.3 – 1.5 g/kg/day) To replace nitrogen losses from tissue destruction characteristic of febrile conditions

3. CHO: liberal intake, simples sugars as glucose may be used; lactose may result to diarrhea

To replenish glycogen storesTo spare protein and provide easily absorbed energy sources

4. Fat: use judiciously Source of energyTo spare proteinToo much may retard digestion

5. Vitamins A, C, B-complex To increase energy and protein intake. Antibiotics and drugs interfere with B-complex synthesis

6. Fluids: liberal (as much as 2.5 -4 liters/day may be lost from excretion (urination, perspiration, insensible losses))

To replace losses from the skin, especially if accompanied by diarrhea and vomitingTo permit adequate volume of urine for excretion of wastesTo replace electrolyte losses

7. Consistency: full liquid during high fever progressing to soft diet

For easy digestion and rapid digestion

8. Feeding interval: give as small quantity; more frequent intervals (2-3 hours); at least 8 feedings in acute fevers

To allow adequate nutrient intake without overtaxing the GIT

Acute Fevers

Typhoid Fever*infectious and caused by Salmonella typhosa*transmitted through ingestion of contaminated food, water, or milk

Characteristics:a. If not treated with antibiotics, the illness lasts about 4 weeks; the body temperature gradually increases for 5 to

7 days and then plateaus as 39⁰-40⁰C (102⁰-104⁰F) for 2-3 weeks then gradually decreases in the fourth weekb. Enlargement of lymphoid tissues in the intestines (Peyer’s patches) particularly the terminal ileumc. Erosion of blood vessels and haemorrhage due to necrosis in hyperplastic Peyer’s patchesd. Perforations of the bowele. Anorexia and weaknessf. Loss of tissue protein, depletion of body glycogen, diarrhea

Treatment: with appropriate antibiotic treatment, improvement begins within 48 hours and the temperature returns to normal in 2 to 5 days

Diet Rationale1. High kcal, high PRO To prevent excessive catabolism of tissue protein2. High CHO To replenish glycogen stores3. Liberal fluids To maintain water balance4. Low fiber, low residue, bland Avoid further irritation of the GIT5. Small frequent feedings Avoid further irritation of the GIT

Rheumatic Fever (RF) - acute or chronic inflammatory process that comes as a sequel to haemolytic streptococcal infection, usually after 3-4 weeks

*it occurs frequently in children and tends to recur*the inflammatory process initially affects connective tissues, but can spread to many organs; when pronounced, myocarditis and arthritis occur*Acute rheumatic fever: characterized by a sudden onset with high fever and swelling and pain in the joints*Recurring episodes of rheumatic fever can lead to damage of the heart muscle and heart valves, a disorder called “rheumatic heart disease”

Diet Rationale1. During acute phase: full liquid to soft diet -easy digestion and rapid absorption2. Mild Na restriction -due to edema especially if steroids are prescribed3. Kilocalories: normal to high levels -to maintain DBW4. Vitamin C supplements -to replace losses due to infection

Poliomyelitis (commonly called polio or infantile paralysis) – an infectious disease caused by one of three polioviruses. The nonparalytic form lasts for periods ranging from a few days to a week and is characterized by fever, malaise, and nausea and vomiting, and back stiffness. The paralytic form has all the clinical signs and symptoms of the nonparalytic type plus paralysis. The large proximal muscles of the limbs are often affected, and in the bulbar type of polio-myelitis, the brain stem and spinal cord are affected

Characteristics:a. Fever, sore throat, headache, vomiting, and often stiffness of the neck and back in the early stageb. Later the central nervous system is involved with paralysis and atrophy of the muscles, ending in contraction

and permanent deformity

Types:1. Spinal – paralysis of the skeletal muscles2. Bulbar – affects brain nerve cells resulting in the dysfunction of the swallowing mechanism

Diet: During the acute stage, the dietary management is the same as in other acute fevers. Bulbar poliomyelitis needs special dietary management because of the difficulty of swallowing. Seifert’s recommended program for bulbar poliomyelitis:

Diet RationaleStage I - Tube feedings of 30 to 50 ml gradually increasing to 200ml alternately with water every 2 hours

Due to dysphagia and to avoid choking

Stage II – Tube feedings and 1 tsp diluted fruit juice, gradually adding other clear liquids

To test swallowing ability

Stage III – Tube feedings and addition of soft, bland, low fiber foods

To initiate normal eating process

Stage IV – Tube feedings gradually reduces while more solid foods of soft consistency are added

To resume normal eating process

*Nutrition intervention is very important due to the high fever, nausea, vomiting. Foods that tend to produce mucus, usually milk and cream, are generally not tolerated and should be avoided

Cholera – an infection of the intestines producing sudden and massive diarrhea causing water and electrolyte lossesSymptoms: diarrhea, sometimes vomiting, causing dehydration, shock and ultimately death

Diet Rationale1. IV fluids recommended To replace fluids lost2. Oral administration of electrolytes & glucose Glucose aids in the reabsorption of Na and water from the

intestinal tract and stool3. Clear liquids initially, progressing to soft, bland diet To rest the GIT and provide easily digested and absorbed

foods4. Fat: restricted, milk is also reduced Poorly digested5. CHO and PRO: high CHO needed to replenish depleted glycogen stores and to

spare protein. Protein will be used to compensate for the increased tissue catabolism

6. Fluids: liberal amounts; 2500-5000ml/day given in small but frequent feeding

For fluid replacement

Chronic Fevers

Pulmonary Tuberculosis (PTB) – an infectious disease caused by the tubercle bacillus, Mycobacterium tuberculosis, which invades the lungs. It is usually transmitted by airborne droplets produced by a person with untreated tuberculosis. It affects the lungs most often but may also be localized in other organs such as the lymph nodes or kidneys, or it may be generalize. Tuberculosis is common among persons with HIV infection.

Characteristics:a. PTB is associated with wasting of tissues, exhaustion, cough, anorexia, expectoration, fever usually in the

afternoons or evenings, and night sweats (cold clammy perspiration even during cold weather)b. The acute phase resembles pneumonia, with high fever and increased circulation and respirationc. The chronic phase is accompanied by low-grade fever and the metabolic rate is lower than in acute illnessd. Because of the protracted illness, wasting may be considerable

Management:1. Drugs

a. Primary drugs1. Isoniazid (INH) – isonicotinic acid hydrazide, an antagonist of vitamin B6

2. Ethambutol3. Streptomycin4. Para-aminosalycylic acid: can cause malabsorption of vitamin B12

b. Secondary drugs

1. Ethionamide2. Pyrazinamide3. Cycloserine

2. Diet

Diet Rationale1. Energy: High kilocalorie (2500-3000 kcal) To achieve desirable weight2. PRO: High To help generate the serum albumin levels which are often

lowTo promote healing of the tuberculosis lesions

3. Minerals: Ca Fe supplementation

To promote healing of the tuberculosis lesionsNeeded if there has been haemorrhage

4. VitaminsPreformed Vit. A increasedVit. C

Vit. B6 supplementation

B complex vitamins

Vit. DVit. K

Carotene is poorly converted to Vit. ATo replace losses, to promote resistance to infections, for wound healingTo protect against peripheral neuritis due to INH antagonism of vit. B6

To stimulate appetite and to improve utilization of CHO and PROFor better absorption and metabolism of CaAnti-hemorrhagic factor

5. Fluid to Soft to Regular diet In acute stage, due to poor appetite6. Meal frequency: 5 to 6 meals a day Due to poor appetite, to increase food intake

Emphysema – it is a lung disorder characterized by enlargement of the air spaced beyond the terminal bronchioles and pathologic changes in the walls of the alveoli

Characteristics:a. Occurs primarily in men over 40 years of age with long history of cigarette smoking and bronchitis. Other

possible causes are air pollution, asthma, and respiratory infectionsb. Exertional dyspnea is often the first symptom and may be accompanied by chronic cough, wheezing and

fatiguec. The course of the disease may be slow over many years or it may progress to the terminal stage in a few yearsd. In early stages, some patients may be obese, and the distress in breathing is further accentuated. Some

improvement is noted if weight is brought within desirable levelse. Shortness of breath places severe limitation upon the ability to ingest an adequate diet, chewing and

swallowing require further effort and the patient often stops short of satisfactory intake

Diet Rationale1. Provide adequate kilocalories (BEE x 1.5) To counteract weight loss and tissue wasting2. PRO: 1.2-1.5 g/kg Body weight To correct tissue wasting3. Consistency: soft, low fiber, bland Require minimum chewing effort; provide non-distending,

non-stimulating, non-irritating food4. Small frequent meals, eating slowly is emphasized To increase caloric intake; to avoid swallowing too much air

*Avoid gas-forming vegetables and encourage intake of plenty of fluids (2-3 liters/day). Restrict Na if there is pulmonary edema and monitor for effects of nutrient-drug interactions. Supplementation with vitamins and minerals may be necessary if intake is inadequate. Provide high-protein supplements for snacks to correct any tissue wasting.

Malaria – a recurrent infection caused by protozoa of the genus plasmodium and transmitted by Anopheles mosquitoes*It may be spread by blood transfusion or by the use of an infected hypodermic needle

Symptoms: intermittent attacks of chills, fever, and sweating, debility, hypochromic anemia, and swelling of the liver and spleen

Diet Rationale1. Kilocalorie: High Level depends on body temperature and rate of tissue

catabolism2. PRO: high To replace losses due to infection3. CHO: Liberal To replenish glycogen stores4. Fats: moderate Due to enlargement of the spleen5. Salts & Fluids: liberal to high To replace losses

Human Immunodeficiency Virus (HIV)*a type of retrovirus that principally attacks CD4+ T-cells, a vital part of the human immune system and causes acquired immunodeficiency syndrome (AIDS). Consequently, the body’s ability to resist opportunistic viral other infection is greatly weakened*AIDS is viral infection caused by the human immunodeficiency virus (HIV)*levels of CD4+ (helper) and CD8+ (non-helper) subsets of T cells are used in evaluating immunological competency in HIV/AIDS; after identifying the levels, stages of HIV infection range from stages 1 to 3 according to severity of depletion

I. Etiology*a retrovirus HIV, invades the genetic core of the CD4+

or T-helper lymphocyte cells which are the principal agents involved in protecting the body from infections

II. Mode of Transmission*HIV can be transmitted via blood, semen, pre-semenal fluid, vaginal fluid, breast milk other body fluids that contain blood*Persons at risk include homosexual or bisexual males, haemophiliacs, intravenenous drug addicts, heterosexuals with multiple partners, and infants of HIV-positive mothers (especially those who are breastfed)A. Sexual transmission – sexual intercourse between men, between men and womenB. Introduction of contaminated blood or blood products

Possible Causes:1. People who received transfusions or blood products contaminated with HIV2. Use of contaminated needles for injection and skin-piercing instruments

C. Infected mother to child1. Through the placenta during childbirth: exposure to infected blood and vaginal secretions2. Through breastfeeding shortly after birth

III. SymptomsA. May be asymptomatic – no visible clinical signs but laboratory tests show reduced number of T-helper cells

or T-4 lymphocytes, or is HIV-positiveB. Symptoms and signs include fever, chills, sore throat, headache, tachypnea, anxiety, fatigue, night sweat,

hypoxemia, dyspnea on exertion, rales or rhonchi, cyanosis, pneumonia, diarrhea, cryptococcosis, severe viral infections, ulcerating herpes simplex lesions, meningitis, anorexia, inflamed mouth or esophagus, malabsorption, weight loss, and poor nutritional status

IV. TreatmentThere is no cure for AIDS and HIV-infection. Some drugs – acyclovir, AZT, amphotericin B can slow down the degenerative process wrought by HIV on the immune system but once one is infected with HIV, he/she is HIV-positive for life

V. Nutritional CareNutrition has both direct effects (immune-cell trigerring) and indirect effects (on DNA and protein synthesis) on the progression of HIV stages. High intakes of niacin, vitamin C, and thiamine have been found to slow the progression from HIV infection to full-blown AIDS; increased zinc intake has been correlated

significantly with rapid progression. Use of antioxidants (vitamins A, C, and E, selenium, and beta carotene) might have beneficial effects.

1. Educate the HIV-infected and persons with AIDS on the importance of consuming a well-balanced diet.2. Provide adequate nutrition for maintenance or improvement of nutritional status.3. Prevent protein-energy malnutrition and vitamin and mineral deficiencies.4. Educate patient about food safety because of vulnerability to food-borne pathogens.

Diet1. Energy depends on health status

a. BEE x 1.3 for maintenance; BEE x 1.5 for weight gain2. Protein: 1.0-1.4g/kg body weight for maintenance 1.5-2.0g/kg for up-building3. Low-fat, low-lactose, low-fiber modifications if there is malabsorption or diarrhea4. MCT oil more readily absorbed than long-chain triglycerides5. Electrolytes Na, K, Cl replacement with vomiting and diarrhea6. Supplementation with beta-carotene, vitamin E, ascorbic acid, vitamin B12, vitamin B6, and folic acid7. Low-bacteria diet8. Total Parenteral Nutrition (TPN) if enteral feeding is not adequate