DIP Ep 631-Travel Medicine Part A (super HY with numerous integrations, for Step 1-3)

All right, welcome. My name is divine. This is episode 631 of the divine intervention podcasts and into these podcasts We're going to be addressing a topic I title travel medicine This is going to be a two-part series because it's just going to be too much to load into one podcast Okay, it's going to be a two to three part series But I'm going to try to keep it to two parts And the thing about travel medicine is number one It tends to contain a bunch of obscure things Number two, these obscure things tend to drop a lot on the USM in the exams. Number three If you just know a few key things you're going to be pretty good to go with these topics and then number four The USM is they really do want you to emphasize mechanisms in your understanding of these topics, okay? So we're going to try to address this in a format that's going to be very helpful to you for your USM in the exams. All right So First things first, what if they give you a question about a patient that is about to travel to someplace and requires pre-travel vaccines How long before traveling should those should you give those people those necessary vaccines? Well, I hope you're picking the answer choice that talks about two to four weeks, right two to four weeks The thing is you want to give these vaccines two to four weeks before the pressing travels. Why? Because you want them to amount and adequate antibody response You want them to mount an adequate antibody response And the thing is sometimes you may even have to stretch out that timing to longer than four weeks if it's a vaccine that requires Multiple doses. That's something you definitely want to keep at the back of your mind for your exams, right? And again In thinking of this topic just think of the population you're giving the vaccine to right? So just be mindful of that right? So like for example if a person is immunocompromised, let's say the acidity for count is less than 200 or The person is pregnant, right? Or the person has some kind of immunodeficiency disease You would know to not give them a live attended vaccine, right? So something like the yellow fever vaccine that will not be smart or a person like the oral typhoid vaccine. That's live attended Right, I mean, yeah, that's that's live attended right or the MMR vaccine right things like that Don't give it to those people those special populations people under age one people that are pregnant People that have CD4s under 200 right or people that have immunodeficiency diseases. No, it's not gonna be a smart idea for those people, right? But then you know many of the other you know vaccines right like the inactivated vaccines things like hip A, hip B Right typhoid the injectable one right so don't mess this up on you exams, right? The oral typhoid has two kinds of vaccines. There's the oral one and there's the injectable one The oral one is live attended the injectable one is An inactivated vaccine right is an inactivated vaccine. So for persons even are compromised don't give them the oral typhoid Give them the injectable thai foid vaccine again. It's little details like this that kind of mess people up on their exams, right? So just something to keep in mind for your for your test All right, so I think the first bug we should talk about probably the one that is tested the most frequently is malaria Right, so let's talk about malaria right so we know that malaria again Having mosquito netting is very very helpful in prevention, right? That's a very simple thing to do very very helpful in prevention, right? Very very helpful in prevention Right in fact, that's gonna be a method of primary prevention, right? You basically like have the net right? You know like a pesticide treated net and then that reduces your risk of being beaten by the anophilus mosquito, right? Remember maliarez caused by the plus modium species and those plus modium species are carried by the anophilus mosquito, right? So one classic thing they love to do on the US Emily exams is that they love to test the drugs Use for maliarez prophylaxis and sometimes they love to test the mechanisms of action of those drugs and they're not just only the mechanisms of action of those drugs But the contraindications to those drugs you absolutely need to know this for you exams. So the drugs used for maliarez prophylaxis The contraindications to those drugs and some basic mechanism of action detail on those drugs, right? So like for example the first one is gonna be a tovacoan proguenil That is like a very classic one details on the exams at tovacoan proguenil, right? Basically this one it does two things right it inhibits the electron transport chain and it shuts down for lit synthesis Right and the reason that this is probably like the most common one tested on the US Emily Exams is that there is very little resistance to it But if you have bad kidneys you have no business being on a tovacoan proguenil, okay? If you have bad kidneys, you better not be on it another classic one you mentioned you exams is Methyloquine methyloquine don't worry about the mechanism of action for your test But this one they love it just think of mechfloquine as the Contraindicated in the crazy, okay? Think of it as being contraindicated in the crazy. What do I mean by that? If you have a history of like a seizure disorder, right or psychiatric condition, right? Do not take methyloquine, right? And also if you have like cardiac conduction problems, right? Like you have like AV nodal disease for example Methyloquine is not a good idea at all now is there are there some other Drugs on the US Emily exams that are not necessarily for my Luria But are kind of like neurotoxic to raise like maybe you want to be careful about giving this to people that have a history of like whatever's You want to think about Interfernal alpha interfernal alpha is a big one remember we use that to treat hep C If you have a history of like measure the perceived disorder or suicidal ideation I mean to for an alpha is maybe not the best idea, right? Maybe not the best idea in those circumstances, all right Let's keep going right and then doxycycline Great doxycycline remember this is a 30s inhibitor, right? It's a 30s inhibitor is a 30s inhibitor is a 30s inhibitor That's something you absolutely need to know for your exams for so it's a protein synthesis in inhibitor, right? Remember doxycycline Is okay in kids you can give it to kids even under age eight Right, but again the US Emily's they are still Larry of you giving doxycycline to people that are pregnant Right the US Emily's they don't really like doxycycline in the pregnant right just something I want to keep at the back of your mind on you exams Just want to keep at the back of your mind for you exams and there's not much resistance to doxycycline Doxycycline is pretty it's pretty effective now One thing you want to know about doxycycline is they can give you a question about a person that took doxycycline For malaria prophylaxis right and then they travel to a tropical area and then they tell you that they've been having this skin Rush that seems to worsen whenever they go on the beach whenever you see that I would really hope you're thinking about the Photo sensitivity that goes with tetracycline Okay, it is very high yield for purposes of you exams to know the drugs that cause photo sensitivity There's a very nice to money. You've probably heard from back in the day called sad for photo Sad for photo the S stands for so phonomites the East stands for immutable room and the distance stands for tetracycline Right those drugs are straightover photo sensitivity right and then there's some other disorders you mission you exams that are So photo sensitivity right so things like Chidiaki Gashi right photo sensitivity Things like lupus also are so photo sensitivity right so just something Want to keep at the back of your mind for your for your test all right and then let's go back to the malaria drugs right and then chloroquine right chloroquine The the key thing to know here is there's a lot of resistance a lot of resistance and it pretty much inhibits Him synthesis right in the in Plasma medium species right but again, there's like wide wide wide widespread resistance wide wide wide spread resistance However, one high yield thing you want to know for purposes of your exams is that chloroquine can cause a Rethnopathy right when you use chloroquine chronically it can cause a Rethnopathy is there another drug that it kind of sounds like chloroquine like an also cause a Rethnopathy I hope you're saying yes, that's gonna be hydroxychloroquine right the thing that everybody thought could magically cure COVID right even if it doesn't really do that or it does it to a limited extent But hydroxychloroquine also causes a Rethnopathy right remember hydroxychloroquine is one of these drugs That you can actually use to treat like rheumatoid arthritis in people that are pregnant right because remember if you have area on your Pregnant maybe it's not a good idea to take method of trixate. You know, you probably don't want to kill the baby right so I mean that's where comes Times you want to consider using a hydroxychloroquine. It is safe in pregnancy But remember hydroxychloroquine can absolutely cause a Rethnopathy okay? Hydroxychloroquine can absolutely cause a Rethnopathy you need to know that for your exams and One other thing I'm gonna say about malaria before I kind of wrap this up with malaria is don't forget many of these Malira drugs especially primal quit remember primal quit is a drug we can use for malaria right but under use is You know to kill the dormant forms that can stain the liver like plus modium vivax and ovali right those hypnozoid forms they can stay dormant in the liver Primerquin is pretty good for those right but remember primal quit is a very powerful oxidizing agent right so the thing is because it's a very powerful Oxidizing agent is not a great idea and people that have g6 pd deficiency right so They can give you a question about a person that's about to initiate Primerquin therapy and then they can ask you like oh what is the most appropriate next best step in management You want to pick the answer that involves are screening them for g6 pd checking their g6 pd levels right or they can give you a question about a person that is given Primerquin and you know a few days after they get the primal quit you notice that they have an increase in their Interimidial Rebellion right and you notice that they have like John this and then they can ask you about the mechanism Behind their symptoms right you can talk about impaired Regeneration of glutathione, okay? Big the answer choice that talks about the impaired regeneration of glutathione. Let me tell you something here, right? I know some of you may be like divine Why are you talking about the impaired regeneration of glutathione? wouldn't it make it simpler like g6 pd deficiency or Impaired any dp-ish production to be honest with you if that's what they did on the exams Everybody will get a 270 on the exams clearly that does not happen You know why that does not happen because that's not how they tell you? test information. On the US similarly exams, they test information with the priority to see if you can think beyond just the surface level. If you can think beyond just the surface level. Because remember, the reason why G6 PD deficiency is such a problem. And by the way, remember, it's excellent, recessive. So it's going to be like a man problem on your exams. But the primary problem is that if you have a deficiency of glucose 6.4 feet, dehydrogenase, you're not going to be able to make any DPH. And any DPH is necessary for glutathione regeneration. Because remember, glutathione is the thing that helps us de-woodoxidative stress, right? Helps us de-woodoxidative stress. So they want to keep at the back of your mind for, for example. Right. Now, let's jump on. So talk to one Malirium, trying to again, hit the high-yield things. Let's talk about travelers diary. Travelers, diaries, another very common thing you may see on your test. Right. Now, one classic thing when I keep at the back of your mind is this, what is the most common cause of travelers diary? What is the most common cause of travelers diary? It's going to be E-Tech, right? Enterotoxygenic E-coli. Enterotoxygenic E-coli, right? And the thing is typically is going to cause a watery diary. Right. But the thing is, there is one point of contention, our friends at the MBM is like to bring to basically kind of throw you for a loop on your test. So basically, kind of throw you for a loop on your test. And that's something I think I want you to keep in mind for your for your exams, right? What is that thing? The thing is, GRD can also cause a travelers diary, right? GRD can also cause travelers diary. And sometimes the presentation can be almost identical to E-Tech. So one classic thing people ask me is, define, how can I differentiate GRD as the cause of travelers diary from E-Tech as the cause of travelers diary? Look at your timeline. If the person has travelers diary that is lasting for just a few days, think about E-Tech, think about enterotoxygenic E-coli. But if the person has travelers diary that seems to last for weeks, and then you see an dissidents of like Stiadoria, like Fatma absorption, like Fat in their stool, you want to think more along the lines of GRD, you want to think more along the lines of GRD. I may wonder like, divine, what is the mechanism? Why does this happen? Well, the thing is GRD literally damages your intestinal mucus. It literally damages your microbiology. If you damage the microbiology, do you think you're going to be able to reabsorb things very well? Not really. You're not going to be able to reabsorb things very well at all. So if that happens, you're going to have my absorption, right? And Stiadoria is a very good finding in my absorption. And then you're like, divine, why does it last so long? Well, the thing is, it kind of takes the body a little bit of time to pledge the idea. And also, after GRD has destroyed your microbiology, it takes a while for those microbiology to get regenerated. Right? So that's why their symptoms tend to be a little more long lasting. Again, if you understand the pathophys like this, you're not just mindlessly memorizing details. Alright, now let's delve a little deeper on it. Right? Because again, classic thing they love to test on the example is, hey, how does it cost problems for you? It does not necessarily damage your microbiology. So it doesn't cause my absorptive problems. What it does is that it has two toxins, right? It has a heat libel toxin and a heat stable toxin, right? And the heat libel toxin, heat libel toxin, what does it do? The heat libel toxin activates at any late cyclist. When you activate a late cyclist, right, you're going to make a convert it to cyclic AMP, right? You're going to stimulate protein kinase A. And that's going to cause you to dump a lot of chloride ions into the lumen of your GI tract. As you dump all the chloride ions into the lumen of your GI tract, it's going to attract water. And then that's going to cause you to have diarrhea, right? The heat stable toxin is going to activate guanilit cyclists, right? It's going to activate what guanilit cyclists, right? Guanilit cyclists. When you activate guanilit cyclists, you're going to convert GTP to cyclic GMP. And then cyclic GMP is going to activate protein kinase G. And we activate protein kinase G. You're going to make a lot of a, you're going to also again, secret a lot of chloride into the lumen of the GI tract. So water is going to follow and you're going to have a diarrhea. But let me ask you this, what kind of diarrhea is this? What kind of diarrhea will that be? It's going to be a secretory diarrhea because that's the mechanism behind the diarrhea, right? A lot of chloride ions are being secreted into the lumen of the GI tract. And then water is following and then you are having diarrhea. So it's going to be a secretory diarrhea. Contrast this with a person having G. Adial diarrhea that tends to be more of a malabsorptive diarrhea. Okay? So again, on your exams, they can literally give you an E-Tech question. And instead of putting E-Tech as the answer, they will just put secretory diarrhea as the answer. Or on your exams, they can give you a G. Adial question. And instead of putting G. Adial as an answer, they will just put malabsorptive diarrhea as the answer. Again, please be aware of surrogates. Basically, I like to think of the USMELISAs follows. I like to think of it as an exam where they want you to know as given concept in six different languages, right? Because they can present any of those six different languages. But the thing is you may ask yourself divine, how am I able to pick up on these six different languages? Honestly, the best way is to just understand pathophysiology. The thing is when you understand pathophysiology is almost like you understand how those six different languages were created, right? So if they give you an example that is novel on usual, many times is still going to reflect that on the line pathophysiology should have understood in the first place. Okay? So again, remember, E.Tech mostly causes a secretory diarrhea. It's going to be a watery diarrhea. They can have a lot of cramping, right? And typically when you check those people's stalls, you're not going to see white blood cells, you're going to see blood in their stalls. And how do we treat E.Tech? Well, you can treat E.Tech with a fluoroquinole, or you can use E.Tech through my simple lupair mind, right? A fluoroquinole or E.Tech through my simple lupair mind. Remember lupair mind is a weak, mu opioid receptor agonist, right? So that can help the diarrhea by basically causing a milder constipation, right? And then remember, GRD again, long-lasting diarrhea is going to be greasy, right? Science of asthma absorption, they can have bloating, they can have fast-melting stools, I'm going to manage that with metronidesol or T. Needsol, right? And then if you see a person that has bloated diarrhea and it's travelers diarrhea, I really want you to think of Campylo-backter or think of Shigella. Think of Campylo-backter or think of Shigella. Believe it or not, even if many times these are tested in terms of mainstream gastroenteritis. They can also be tested on the US Emily exams in the context of bloated diarrhea, travelers diarrhea, okay? So keep that at the back of your mind for exams, right? So like for example, Campylo-backter, if they give you a question about a person that has bloated diarrhea and then they tell you that the person has like lower extremity weakness, then I want you to think of that person having Campylo-backter G.G.9 infection, right? Because that low extremity weakness tells you that this person has Guillain-Barrez syndrome, right? Guillain-Barrez syndrome and again, we're gonna manage it with is it through my sin or you can use a fluoroquine alone, right? Again, if you're, I want annoying things our friends at the MB miscandruis, they can give you both as answers, they can give you is it through my sin as an answer, they can give you a fluoroquine alone as an answer, if they give you both as answers, which one should you pick? The US Emily's totally do this to people all the time. They'll give you two right answers that work for the question, but one is a better answer than the other. If you see those pick is it through my sin, pick the microlyte answer. Why? Well, the thing is there is less resistance to microlytes compared to fluoroquine alone, that's number one. Number two, fluoroquine alone has a lot of toxicities, right? They can do things like explode your Achilles. They can cause an Achilles tendonopathy and they can also prolong the cutie interval. The only problem you're worried about with is it through my sin is that, hey, this could prolong my cutie interval, but at least it does not explode your Achilles and there's not as much resistance as we have with fluoroquine alone. All right, and then Shigella, right? Shigella, again, bloody diarrhea, very high fevers, right? They may have signs and symptoms of the hemolidic uremic syndrome. So if you see a person having bloody diarrhea and they have like big-time thrombocytopenia, right? They have big-time thrombocytopenia, right? They have like elevated creatinine. They probably want to think more about Shigella as the cause of their travellers diarrhea as against Campylobacter, Gigiunai. And again, you can treat this with a fluoroquine alone or is it through my sin? Right? So hopefully like you're beginning to see kind of a trend here. Many of these travellers, diarrhea causes can be controlled very well with the Zythromycin or a fluoroquine alone, right? Zythromycin or a fluoroquine alone, right? The one big exception of talked about today is a G-ardia, right? That we use metronidazol or tiniethazol for, right? Make sure you know the bugs that are covered by metronidazol, right? There's this nice, the one you've probably heard, get gap on the metron, right? So like G-ardia and tamiba histolidica, that's the E, right? So get gap on the metron, right? So G for G-ardia, E for intamiba histolidica, the thing that causes amybiasis, the T for trichomoniasis, right? And then the G, other G for ganyola vaginalis, the A for anerobs and then the P for protozoans, right? Those are the drugs that, those are the bugs that are covered by a, by a metronidazol. All right? And then the last thing I want to talk about travellers diarrhea, this is actually something they love to test and this is something that gets a lot of people because people don't think about this as a potential cause of travellers diarrhea. But think of cryptosporidium parvin. Think of cryptosporidium parvin. Cryptosporidium parvin. And you're going to see after the discussion I have on cryptosporidium parvin, why do you really love to test it a lot on the USMELIS? There isn't a lot to test it all along, the USMELIS is that there are so many integrations you can make with cryptosporidium parvin for your exams, right? So many of us know the classic, oh, you see watery diarrhea in a HIV patient, cryptosporidium parvin, right? And many times they will talk about the acid fast osis in the stool. Remember, cryptosporidium is acid fast, is acid fast. So if they tell you about a person that is immunocompromised and the person has acid fast osis in their stool, think of cryptosporidium parvin, okay? And remember that cryptosporidium parvin. So, the third problem is treated with Nytus oxenite. Strictly the drug, Nytus oxenite. Nytus oxenite. Now, the thing is our friends at the NBM is they know that everybody that has the job description medical student or USMD exam taker has memorized. Cryptosporium causes, Vyrein, HIV patients. Right, so what do they do these days? They like to test it as a cause of Travellers Diarrhea. Okay, but it's going to typically present as Travellers Diarrhea in an immunocompromised person. Or, it can prevent as Travellers Diarrhea in an immunocompetent person and then they will give you the stool results. They will say that, "Oh wow, this person is immunocompetent, you know, the person doesn't have any HIV or immunodeficiency disease." But the person has Diarrhea, you know, profuse watery Diarrhea and then they tell you that, "Oh, they do some testing of the stool and they find acid fast oses." When you see that, then you want to think about Cryptosporium Parvam, right? So, if you see a Travellers Diarrhea context in a person that is immunocompetent and you see acid fast oses in the stool, the person has Cryptosporium Parvam infection, right? And again, remember Cryptosporium Parvam, right? It's an intracellular protozoan, right? It likes to infect your small intestinal epithelium, right? That's why it causes nasty, nasty, nasty Diarrhea. Okay? So, the thing is, believe it or not, people can also get Cryptosporium Parvam from swimming in pools that are chlorine treated, right? Because the thing is chlorine does nothing to Cryptosporium Parvam. That's actually something that is pretty high to know for you exams. A chlorine treated pool does not mean that Cryptosporium Parvam has been killed, right? So again, like I said, it can present an immunocompetent people or it can present a immunocompromised people, right? In fact, the thing is, most times when people are immunocompetent, you don't have to treat them. They don't need nitrous oxide. Right? So think of nitrous oxide as something you do for a person that has C-parvam infection that is immunocompromised. That is immunocompromised. Okay? So, the thing is, if a person is immunocompetent and they have Cryptosporidial Diarrhea, self-limited, you know, within a week or two, they're going to get better. They're going to get better. Right? And why do they get better? Well, because they have functioning immune systems. Let me tell you this. your CD4 positive T cells are extremely critical for dealing with Cryptosporidium Parfo. I'm going to see that again. Your CD4 positive T cells are extremely critical for dealing with Cryptosporidium Parfo infection. So if you're a personalized immunocompetent, you have well-functioning CD4 positive T cells. You're going to clear that infection. But if you're a person that has HIV, you'll see that your CD4 positive T cells have been nuked and destroyed, then in that circumstance you're probably going to struggle with this infection. So if you see a person that has cholera-like diarrhea and immunocompromised like a HIV patient, think of Cryptosporidium Parfo infection. Many times it's going to show up as a nasty, nasty infection. A person that has a very, very low CD4 count. Typically it's going to be a person that has a CD4 count that is under 200. So you're going to see it presents just severe, chronic, nasty diarrhea. They can be popping more than 10 liters of fluid a day. Severe, nasty, chronic diarrhea. They will have a nasty malabsorption. A lot of weekdays, they'll be super dehydrated. The thing is, one strange association, the friends at the MBMEs love to test with Cryptosporidium Parfo is that it can spread to your biliary tract. It can cause a sending cholangitis. It can cause acute pancreatitis. It can literally spread to your biliary tract. So the thing you may be asking is, divine, why do they love to test it in people that have CD4s under 200? Again, it can happen in people with CD4s over 200. But classically, when they are testing a HIV patient that has Cryptosporidium Parfo infection, their CD4 count is usually going to be less than 200. Why is that? Because again, the people that are more likely to get this are people that have severely clobbered CD4 positive T cell count. And hey, if your CD4 positive T cell count is under 200, you're going to have a severely clobbered count. That's going to make it very, very difficult for you to be able to clear the infection. In fact, let me tell you this. Whenever you see me laugh like this, it's because it's like, "Oh, this is another thing that you don't want to use in many exams to people." See, on the exams, they can give you a question about a person that has poly-controlled HIV. They'll tell you the person has not seen the physician in many years. And then they describe this person in CD4 count as being like 60. And then they tell you that the person has had like profuse, watery, fast-milling diarrhea for the last few weeks. And then they say that, "Oh, a stool study is positive for acid fast osysts." And then they ask, "Which of the following would most likely lead to long-term resolution of these patient symptoms?" Or most likely improve the patient's prognosis? Pick the answer that talks about initiation of antiretroviral therapy. I'm going to say that again. Pick the answer that talks about the initiation of antiretroviral therapy. The thing is, if you put a person that has cryptosporidium problem infection, if you put them on Naita Zoxanide, an immunocompromised person, it will help their symptoms, but they will not completely clear the infection. That infection will stay persistent in those people for a very, very long period of time. If you want to truly clear cryptosporidium problem infection, you need your CD4 positive T cells to come back online. You literally need your CD4 positive T cells to come back online. So Naita Zoxanide, again, it can help, it can help, but it will not completely clear the infection. In fact, again, they can make this a prognosis question. I was discussing this in one of the classes I thought last week. I was thinking people that, "Hey, they love, love, love to test prognosis a lot on the US Emily exams these days." And what is one class equity love to test prognosis? They love to test it in a context like this, for example. In a context like this, you truly will improve a person's prognosis for cryptosporidium problem infection when you initiate antiretroviral therapy. In fact, that is the most important intervention in properly clearing cryptosporidium problem infection. You can give them Naita Zoxanide, but it's basically like a temporizing measure. You want to permanently clear that problem? Go ahead and boost the CD4 positive T cell count by giving them what antiretroviral therapy. Now, one other angle that they love to test with cryptosporidium problem infection on the exams is that they also love to test it in the context of Iris. So they will give you a question about a person that had a CD4 count of 40. And then the person was initiated and the person had like very nasty weeks of watery diarrhea and all these things. And then they ask you, "The person has weeks of watery diarrhea." And then they tell you that, "Oh, pharmacotherapist initiated." Or they can even make it a two-part question. Naita Zoxanide therapies initiated and the patient is also placed on antiretroviral therapy. They can make that the first part of the question. They can test things around those concepts for the first part of the question. And then the second part, they can say that one week after therapy is initiated, the patient presents with like worsening diarrhea, very high fever, severely profound weight loss and profound dehydration. And then they ask you which of the following is the most appropriate next step in management? I would really hope you are picking the answer choice that says to continue antiretroviral therapy, continue Naita Zoxanide. And if necessary, go ahead and give them steroids. So what's going on with this person? Well, this person has something called Iris. This person has immune reconstitution inflammatory syndrome. Immune reconstitution inflammatory syndrome. Our friends at the MBM is the love to test Iris a lot. And many times, they love to test it in the context of cryptosporodium parvin infection. Basically, what is Iris? Iris is basically like, so immune reconstitution inflammatory syndrome. Like literally look at the name, immune reconstitution inflammatory syndrome. You are literally reconstituting the immune system and then you get an inflammatory syndrome from that. So say for example, how would this arise in a person that has cryptosporodium? If you understand this model, then whatever any other model is going to make sense to you. But basically, if a person has cryptosporodium parvin infection, they may not compromise. They're like a HIV patient, really bad HIV. When you start antiretroviral therapy, the CD4 positive T cell count is going to start rising. Now, as that CD4 positive T cell count starts rising, your immune system begins to recover. So your immune system that is recovering is going to be like, I am going to search out every cryptosporodium that is in the body. I'm going to destroy them. So what does your immune system do? The thing your immune system does is that it starts going after tissues that contain cryptosporodium in them. It starts going after tissues that contain cryptosporodium in them. They have cryptosporodial antigens. And that initial inflammatory cascade, because we find cryptosporodium problem in the GI tract, that initial inflammatory cascade, guess what it does? It's going to just absolutely destroy many parts of your GI tract. So that can cause you to temporarily have a worsening diarrhea. So those people may have a temporary worsening of their diarrhea. They may have a temporary worsening of their abdominal complains. But they will get better over time. Just tell them to stay the course. So how do you manage immune reconstruction inflammatory syndrome? So you can temporarily continue anti-retroviral therapy, literally continue the night of the oxygenite. provide them nitrous oxanide, give them antargeo viral therapy because, again, remember, upregulation of their T-cell counties, the most important intervention in controlling and in clearing crypto-sparadion problem infection. But a third thing you should also do for those people is steroids. If it's really, really bad, then consider giving them steroids. Consider giving them steroids. So again, these people see the four positive T-cells, the T-hopper 1-cells, they come back online, right? And remember, your T-hopper 1-cells are involved with cell-meditated immunity. So any cell that contains crypto-sparadial antigens, they're going to start attacking them hard. They're going to start attacking them hard. They're going to literally start attacking them hard, start attacking them hard, right? But again, typically, those people are going to get better over time, right? It's basically a transient inflammatory flare. You know, I just like to think of it this way, right? Like say, for example, if you have not eaten for a long period of time, let's say you've been fasting for seven days. The first time you see food, you're going to eat that food very aggressively. Second time you see food, you're going to eat that food very aggressively, very violently. But by the third plate of food, the fourth plate of food, you're going to kind of slow down a little bit because now you've had food, right? Things are not as bad, right? So the thing is kind of like the same thing happens with immune reconstitution inflammatory syndrome. Your immune system is coming back online, right? So it wants to kind of flex its muscles. It wants to show that, hey, I'm back. But after it kind of flexes its muscles, kind of cleans up. It then kind of goes back to its like normal baseline state, right? So again, you want to keep out the back of your mind for your exams. Okay. So you want to keep out the back of your mind for your exams. All right. And again, remember one other thing that may be used for travelers, the era before I'm kind of don't we travelers the area is don't forget, don't forget travelers, the area one of the ways some people treated is with bismuth subsalicylate, bismuth subsalicylate, right? Now if a person has a, a he's sure of like aspirin allergy, right? Or a person has a he's sure of like aspirin exasperate, aspirin exasperated respiratory disease, giving bismuth subsalicylities maybe not a good idea. Like literally contains salicylic acid, right? So if you have like an aspirin allergy and so we can have profound aspirin allergies, bismuth subsalicylities not a good idea because again, remember bismuth subsalicylate basically contains aspirin. It basically contains aspirin. All right. Now next thing I want to talk about here, what if they give you a question about a patient, right? What if they give you a question about a patient and this patient, you're told that this person, you know, traveled to some foreign country, right? And the person has like extremely high fevers, very severe headache and that they have a retro orbital pain, they have pain behind the eyes, right? They have a lot of myelogies, a lot of astrologers, right? And that this person to move their arms or their knees or their legs, the person, you know, complains of 10 out of 10 severe pain, when you see something and they have a rush on the skin, like a blanching macular popular rush, when you see something like this, please, please, what should you be thinking about? Denge, denge, denge, denge, right? Think of denge on your exams, think of denge on your exams, right? And many times again, these people are going to have PTK and proper on their skin. They may actually have bleeding, right? In fact, there is a reason why it's called dengue hemorrhagic fever, right? They can bleed, right? They can have a lot of plasma leakage and I'm going to discuss the pathophase here shortly, right? But they can have a lot of plasma leakage that leads them to have, you know, they can have like shock, you know, very severe bleeding, you know, multi-organ dysfunction syndrome and things like that, right? And things like that. Now, one thing our friends at the MDM is love to do is that they love to test a lot of integrations with dengue. They love to test a lot of integrations with dengue. So let's kind of talk through dengue, okay? So first things first, what's the bug that carries this? Well, I hope you're saying that UDVINE is the 80s mosquito, right? The 80s, a GTI mosquito, the 80s, AEDES, a GTI is AEDGYPTI, the 80s Egypti mosquito, right? And again, typically, in fact, like if you see a person that travels to a tropical area and they have like very high fever, very severe headache, very nasty muscle pain, especially like retrobidol, eye pain, PTG hyperparamid, the skin, the Kimoses on the skin, right? Think of a person having dengue hemorrhagic fever, right? dengue is actually the most common abo viral disease worldwide. It's literally the most common abo viral disease worldwide. I think there's about a 400 million infections that happen a year. All right, so what are some strange immunology related things that our friends at the MBMs want you to know about dengue? Again, dengue is heavily tested, guys. Dengue is heavily tested. Number one is that when you have a primary dengue infection, it's usually going to be a mild infection, it's usually going to be mostly symptomatic. However, when you have a secondary infection with a different serotype, that infection can be life threatening. It can literally lead to death. Okay, so again, let me break this down. The first infection you have, the primary infection, typically is not as bad as the secondary infection, right? Many times if you get dengue the first time, you're going to have symptoms is going to suck, but it's not going to be as bad as if you have a different infection, a second infection, a second infection with a different serotype. When you see something like this, these people can have very severe symptoms and their mortality is much higher when you have a secondary infection with a different serotype, with a different serotype. So you may be asking like, "Define, why is it that this?" You know, because I've learned in immunology that the first time you encounter an infection, you know, you have like a very severe symptoms, but you know, down the line in the future, it's not as bad. Why do things seem to be different with dengue? Okay, let's break it down, right? And the thing is the mechanism here is something called, the mechanism here is something called antibody dependent enhancement. Antibody dependent enhancement. Our friends at the Indian News, they love to test this on the exams. And for whatever bizarre reason, many resources do not cover this, right? But the fact that many resources don't cover something, does not mean that it's not very, very high you to know for your test. Okay, so let's break this down. If you follow along with this, you're going to be able to keep this in mind, right? So again, what is this antibody dependent enhancement? Well, the thing is dengue has four serotypes, right? Dengue literally has four serotypes. There's denv1, right? Denv2, denv3, and denv4. Right? So the thing is when you have a primary infection, let's assume that hey, the first infection you have is with denv1, right? Denv1. The thing that will happen is when your body sees denv1, your immune system is going to make anti-denv1 antibodies, D-E-N-V-1. Your immune system is going to make anti-denv1 antibodies. These denv1 antibodies, they're going to neutralize, they're going to absolutely just neutralize the denv1. And you're going to feel good, right? You're going to feel good. But one thing people don't realize is that these anti-denv1 antibodies, they have some mild cross-reactivity with a denv2, denv3, and denv4. So they cannot neutralize, they can only neutralize denv1, they can not neutralize denv2, denv3, and denv4. They can cross-react with them, but they cannot neutralize them, right? So let's say, for example, you then get a second episode of dengue. But this second episode you get it with denv2 instead of denv1. I can promise you that this second infection that they have is going to be much, much, much, much worse than the first infection they had. In fact, they can die from this secondary infection, right? So what's the pathophase here? What's going on here? Remember what I said, I said, anti-denv1 antibodies neutralize denv1, but they can cross-react, they cannot neutralize, they can only cross-react with them, two, them, three, and them, four, right? So these anti-denv1 antibodies, what do they do? If you have a secondary infection with them, two, they will bind to them, two, they will literally bind to them, two, but they will not neutralize them, two. The unfortunate thing that actually happens here is that they're actually going to quote the virus and facilitate the entry of the virus into your immune system cells. Whoa, they're going to quote the virus and then facilitate the ability of the virus to enter your immune system cells. Wow, wow, right? Wow, this is something you definitely need to understand for your example. So what's the mechanism here? Well, the thing is when these anti-denv1 antibodies bind like them too, for example, right? Remember, every antibody has a constant region, right? When that constant region can be bound by a kind of receptor called the FC gamma receptor. The FC gamma receptor is a receptor that we find on many immune system cells, like your natural killer cells, your macrophages, right? Sometimes it's called CD16, right? So we find it on natural killer cells, we find it on monocytes, we find it on macrophages, we find it on the energetic cells, right? And this FC gamma receptor can recognize the constant region of IgG. So if you have anti-denv1 IgG antibodies that bind to them too, then the constant region of those anti-denv1 antibodies will literally bind, will be bound, sorry, will be bound by the FC gamma receptor. And then when is bound by the FC gamma receptor, that actually facilitates. It almost provides like a highway for them too to infect your white blood cells very, very effectively to influence your white blood cells very, very efficiently, right? So when that happens, when that happens, then two wrecks hover on your white blood cells. It basically gains a lot of entry into many of your cells. And that causes you to get in very, very severe trouble. Because remember, whenever your white blood cells get infected, they start releasing all those nasty things that they have in the aluminum. But what are those nasty things that they release? Or they release many of these acute phase reactants, you know, IgG, IgG, IgG, IgG, for the grand least things like interlooking eight, right? And the thing is these things cause a lot of inflammation. One of the things they do is that they increase vascular permeability, right? They increase vascular permeability. How by disrupting your tight junctions, right? By disrupting your tight junctions, right? So if you increase vascular permeability by disrupting tight junctions, right? You're gonna cause a lot of leakage of plasma from your blood vessels into tissue spaces, right? From your blood vessels into tissue spaces, right? That's what's gonna cause people to start having all this hemorrhage, right? Cause in all these hemorrhage. And the thing is because a lot of fluid is leaking from your blood stream into your tissue spaces. The hemoglobin that is left behind in your blood stream becomes very concentrated. So these people tend to be hemoconcentrated. These people tend to be hemoconcentrated, okay? These people tend to be hemoconcentrated. So this is why if we're giving you the dengue vaccine, we wanna make sure that it covers them one, them two, them three and them four, okay? So please on your exams, if they give you a question about a person that has a second dengue infection and they develop like very severe disease, very nasty septic shock, very nasty hemorrhage. And they ask you about the underlying mechanism. Think about antibody dependent, think of antibody, think of antibody dependent enhancement. Think of antibody dependent enhancement. Again, the preexisting antibodies you made to the first infection, right? They made the second infection worse, not better. They literally made the second infection worse, not better. Okay, so again, remember, how do we diagnose dengue on the USMEL exams? Again, you can check the NS1 anti-generate or you can just check for antibodies, IgM, anti-i, you can just do your antibody serologies, right? Against dengue, right? You can also do PCR, right? And again, the classic things you're gonna see lab wise, they're gonna have low platelets, they're gonna have thrombocytopenia, they're gonna have leukopenia, their transaminases are gonna be elevated, right? Their LFTs are gonna be up, their ASTLT is gonna be up, right? And they're gonna have a high hematocrate. Again, because of hemoconsentration, because of hemoconsentration, because of hemoconsentration, right? And how do we manage dengue? So body of care, right? Ivy fluids, right? No more saline, right? And please, please, please, please, please, right? (laughs) What is one thing that gets people in trouble on the exam? They're like, oh, divine. It is dengue hemorrhagic fever. So because they have fever, I can give them aspirin or NSAIDs. No, don't do that, right? Literally look at the term that comes before the fever. Chemorrhagic, they are bleeding. Why do you wanna give things that can cause them to bleed some more, like aspirin or NSAID, right? That will not be a very smart idea in those people, right? That will not be a particularly smart idea in those people. All right, now, what if they give you a question about a patient and they tell you that this patient, you know, travel to some foreign country and the person has very, very high fever, right? And the person has jaundice, right? And they give you, you know, the person is extremely hypotensive. And then you notice that they have this element of acute kidney injury, right? And you also notice that they are pretty cardiac. They are pretty cardiac. And they even tell you that, oh, they have like three plus or four plus protein area. If you see something like this, what should you be thinking about? I hope you're thinking about yellow fever. And typically they will give it to a person that is traveling to, that traveled, that has traveled to sub-Saharan Africa. This is why if you're traveling to sub-Saharan Africa, like Nigeria, for example, you know where I'm from, you have to have had a history of the yellow fever vaccine. That's actually pretty high you to know for your exams. Okay? If you're traveling to sub-Saharan Africa, like Nigeria, that is actually one vaccine that is required, right? Say, for example, you're an American in a traveling to Nigeria, you better take that yellow fever vaccine because yellow fever can kill. Yellow fever can kill. If you have severe yellow fever infection, the mortality is about 50%. It's actually pretty nasty, right? Okay, so keep that at the back of your mind for your exams. So again, just to rehash, what are the key things you wanna know about yellow fever for your exams? Again, how does it present? High fever, right? John Dis, right? And typically they'll have that John Dis with Breedy Cardia, with Breedy Cardia, right? And it also causes acute kidney injury. It causes an AKI, right? So you notice a lot of protein in the proteins urine. You mean, you'll see a lot of protein in the proteins urine. And remember, this is carried by the 80s mosquito as well, right? Carried by the 80s mosquito. And then don't forget the sub-Saharan Africa Association or the South American Association, especially within the Amazon Basin, right? And the thing is sometimes, if they wanna make this question harder than it needs to be for your new exams, instead of putting yellow fever as the answer on your exams, they can put flavy virus as the answer on your exam. First, remember, yellow fever is a flavy virus infection. And the thing is, it has a very strong predilection for the liver. It loves the liver. It literally loves the liver. So when it gets to your liver, it infects your hepatocytes and causes necrosis of your hepatocytes. And when you cause necrosis of your hepatocytes, guess what? You're gonna have abumine problems. You're gonna have clotting factor problems. That's why they can have hemorrhage. That's why they can bleed. That's why their LFTs go up. So please keep that in the back of your mind for your exams. Keep that in the back of your mind for your exams. And how can we prevent this? Well, there's a live-atenuated vaccine. There's a live-atenuated vaccine. Again, these vaccines require for entry to many countries. And the thing is, once you get the vaccine once, it's going to give you lifelong immunity. It's literally gonna give you one. Life-long immunity. Life-long immunity. But again, remember, if you're a little kid, under each one, especially under each six months, no yellow fever vaccine for you. If you're pregnant, no yellow fever vaccine for you. If you're a middle compromising, no yellow fever vaccine for you. Or if you have like an egg allergy, no yellow fever vaccine for you as well. Pretty high you to know that for your exams. Or if you have like the George Syndrome, or you have like a skid, no yellow fever vaccine for you. Whenever you have like an absent thymus, the yellow fever vaccine is not a good idea, right? Because that's a correlate with nasty, nasty, nasty immunocompromise. Nasty, nasty, nasty immunocompromise. All right. And generally, if a person is over age 60, he also wanna be careful about giving them the yellow fever vaccine. Because remember, as you get older, your immunocompetence begins to win, quite a bit, begins to win quite a bit. All right. Man, this podcast has gone on for longer than I planned. You know what? Let's maybe go ahead and pause here. Let's go ahead and pause here. I will do another travel medicine. Again, like I said, it's gonna be a two or three part series. Gonna be a two or three part series again. The thing is, for my podcast, I know people say like, oh, divine, you then go off in this direction and then in this direction. The thing is, those integrations will help you on your exams. The USM list, they don't, that's the thing. Like this is probably one of the most common complaints after it with my podcast. The divine, your podcasts are not linear. You keep going in different dimensions. The reason I do that is because that will lead, that's literally a much better way to prep for your exams. It's uncomfortable, but it's a better way to prep for your tests. Right? My goal here is not to make you comfortable, because if I make you comfortable, but I'm not prepping you well for your exams, then what was the benefit of spending 45 minutes or thereabouts listening to me? It's better to deal with discomfort, but it helps you prep well. Growth happens in the midst of discomfort. You've probably heard this term. I guess think of this as a life lesson that necessity is the mother of invention. So just gonna keep that at the back of your mind as you go through your life. All right, so if you love the way I teach, and again, God willing, I'm gonna, we're gonna have another episode, episode six, 32 is gonna be travel medicine part two. But if you love the way I teach, you love the way I make integrations, you're gonna love my classes. Many people have taken my classes and done extremely well on the exams, right? In this month of February, starting next week Monday, I do have a series of classes for step one or the way to step three. So what are my step one or the way to step three classes? Well, I have my test taking strategies class. It's two and a half hours long. I have my bio-statistic class. It's four hours long. I have my social sciences and ethics and quality improvement on hospital medicine class. That's five hours long. Those classes are for step one or the way to step three. But for step two and step three specifically, I have a last minute review that is three hours long. I have a 20 hour step two step three review that is, you know, 20 hours long. And then I have a class that is held only once a year. It's in the month of June. It's a 50 hour, 500 multiple choice questions, step two step three class. I mean, that class is phenomenal. People that have taken the class have done just extremely well on their exams, right? So if you're interested in any of these classes, I'm the one that teaches all of these classes in their entirety. There's not like some TA that's teaching those classes. No, it's literally me over Zoom that teaches the whole class. If you're interested, shoot me an email and I can give you some more information. And then I also have these podcasts on Apple, Google, and Spotify. And also offer one on one tutoring. I also help with applications, right? Like Eras applications, mock interviews, personal statements, rec letters, and things like that. Right? And then I have another website called divininginterventionlifelessons.com. Divininginterventionlifelessons.com every week. You know, many of you know, a lot of Christ follower. I post like one or two podcasts from a biblical perspective address a life lesson. There's actually an Apple podcast associated with that called the Diviningintervention Life Lessons podcast. And then don't forget that I have a YouTube channel where I'll suppose the videos that I make. So thank you for listening to me in today's episode. Again, I know it was kind of a lot, but again, there's so many exam questions you're gonna get right from this stuff that are not even related to travel medicine. So thank you for listening to me. Have a wonderful rest of your day. God bless you. I'll see you in episode 632. Bye for now.