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Ondine’s curse and primary alveolar hypoventilation

Ondine’s curse maybe a familiar phrase to you, after going through the respiratory system topics.When I came across this story in my PG entrance book, I wanted to know more about Goddess Ondine and Ondine’s curse.

Ondine (ballet)

Ondine (ballet) (Photo credit: Wikipedia)

Ondine was a water goddess, a nymph in French foklore written by Friedrich de la Motte Fouqué. Nymphs are immortals.If a nymph falls in love with a man and bears his child,she will become mortal and age like a mortal woman, thus losing her eternal youthfullness and beauty.

When Ondine saw the handsome young Palemon she was smitten and began to watch for him on his daily walks. When Palemon noticed her, he was taken by her incredible beauty and came back frequently to try to get a glimpse of her again.

Eventually they talked and fell in love. He broke his engagement with the young noblewoman Berta and, in time, convinced Ondine to marry him. When they exchanged their wedding oaths, Palemon vowed that “My every waking breath shall be my pledge of love and faithfulness to you.”

 

 

But it was not to be.

 

The following year Ondine gave birth to their son. From that moment on, her beauty began to fade, her body suddenly susceptible to the effects of age. As her youthful attractiveness gave way to a more mature beauty, Palemon’s eye began to wander to the younger women he met at court.

 

One fateful day Ondine was out walking on their estate when she heard the sound of Palemon’s familiar snoring. Planning to take him back home so he could finish his nap, the amused Ondine entered the stables to wake him.

 

The scene she encountered filled her with great sorrow. Discarded garments littered the floor and her beloved Palemon lay sleeping in the haystack, his arms wrapped around his former fiance Berta. Having sacrificed her immortality for this man, she was filled with anger and regret.

 

Kicking her sleeping husband, she woke him and uttered her curse. “You pledged faithfulness to me with your every waking breath and I accepted that pledge. So be it. For as long as you are awake, you shall breathe. But should you ever fall into sleep, that breath will desert you.”And so it was.

Palemon would never sleep again.Primary alveolar hypoventilation is another name for Ondine’s curse.

In mammals, rhythmic respiratory activity is generated in the pre-Bötzinger complex, which is formed by a network of six physiologically different neuronal populations Selective lesioning of this neuronal network causes rhythmic respiratory activity to cease,resulting in apneustic breathing also known as curse of Ondine or just as Ondine’s curse.

Bronchial asthma triggers, treatment and precautions.

Bronchial asthma which is often referred to as Asthma is caused by irritation of the airways.

When irritation of the airways occur, the airways contract and hence the width of the respiratory passages decrease and they get filled with secretions causing respiratory difficulty.This inflammation reduces the amount of air flowing through the air passages and cause violent respiratory efforts.

Etiology of bronchial asthma

There are many factors which can trigger an asthma attack,house dust,pollen,cotton dust,cobwebs etc. are some allergens which trigger an attack of asthma.Asthma can also be triggered by exercise, stress, tobacco soke, cold etc.

Children are the most susceptible for asthma.Some children get spontaneous remission in the 11-14 age group.The explanation given is that,as the child grows the child’s immune system gets adapted to the great number of allergens it comes across.

Most of the children affected will have a family history of asthma or atopy.They will have skin manifestations like contact dermatitis, eczema etc.

Mechanism

Allergens like pollen cause degranulation of mast cells.When mast cells degranulate, histamine gets released.Histamine causes the airway mucosa to swell and smooth muscles in the bronchiolar walls to contract causing symptoms of asthma.Histamine also causes local irritation and causes accumulation of secretions in the airway causing further irritation.

Clinical features

Cough

Shortness of breath

Chest tightness

Wheeze

Intercostal retraction

Tachycardia

In severe asthma the wheeze may be audible without a stethoscope. There maybe bluish tinge to lips and tongue(cyanosis) due to increased carbon dioxide(carboxy hemoglobin) in blood.

Investigations

Spirometry

Lung function tests

Chest Xray

Allergen assay

Blood investigations

Treatment

1.Beta 2 agonists like salbutamol,terbutaline etc. are used in emergency management of bronchial asthma.These drugs helps in dilating the bronchial pathways thus allowing more air to pass through.
Salbutamol is available in the form of nebulization and tablets.
In emergency situations salbutamol nebulization is given.

2.Anticholinergic drugs -Ipatropium,Thiotropium

These drugs are given as nebulization along with beta 2 agonists.These drugs help in reducing secretions and help in relieving the bronchial muscle spasm.

3.Steroids- Steroids like dexamethasone are the mainstay of management for bronchial asthma.Steroid reduce the inflammation of the airways and give immediate relief.

For long term treatment of asthma a combination of a long acting beta 2 agonist(terbutaline) and a steroid is usually given.

4.Lekotriene antagonists -Monteleukast and Zafirleukast

5.Inhibitors of mast cell degranulation- Chromolyn sodium.These drugs are mainly used for the treatment of seasonal asthma triggered by pollen, cotton dust etc.

Precautions to be taken

Since dust is the major cause of asthma, frequent cleaning of rooms to avoid accumulation of dust is needed.

Window panes should remain shut during spring season when pollen grains disseminate.

Using of face masks while travelling on motorbikes is a necessary precaution to avoid triggering of asthma due to exhaust fumes.

Compliance and regular use of inhaled drugs as per the advice of the physician.

Why does nocturia occur in heartfailure?

While taking case history in a cardiac failure patient, one of the most important points to be enquired is whether there is a history of nocturia in the patient.

What is nocturia?

The tendency of the patient to urinate excessively during night is called nocturia.Nocturia can be very distressing as the patient having heart failure(before being admitted and catheterised) is unable to walk to the toilet for urination hence may result in bedwetting.Usually patient doesn’t mention this due to embarrassment, so a doctor has to ask specifically about nocturia to extract this precious information.

Why does nocturia occur?

In cardiac failure, the heart is not able to meet the needs of organs which include kidneys due to failure of heart to pump out blood.Due to the failure of heart to pump out blood, it pools in the extremities leading to edema of legs and face. At night when the patient lies down, the blood that had been accumulated in the extremities returns to the heart, hence the cardiac output during the night is slightly increased compared during the day time.This increased cardiac output perfuses kidneys, which in turn produces more urine to decrease the workload of heart resulting in nocturia.

What is syphilis?

Syphilis is a sexually transmitted disease(STD) affecting the genital organs.Syphilis is transmitted by a spirochete bacterium named Treponema pallidum.It is most often transmitted by sexual contact, but it can also be transmitted from mother to fetus by placental route.When transmission occurs from mother to baby and when syphilis is present in an infant it is called congenital syphilis.

Syphilis has been called ” the great imitator” due to its frequent atypical features.Usually after sexual contact with an infected individual, syphilis takes about 9-90 days to establish in a new individual.This period is known as the incubation period of syphilis.During this period the signs and symptoms of the disease are not present.Syphilis passes through different stages in an individual.It can be primary, secondary,tertiary and latent syphilis.

Symptoms of syphilis

Syphilis usually presents as painless ulcer on the glans penis or in the vulval region with painless rubbery lymphadenopathy. The ulcer is described as painless punched out non bleeding ulcer.This painless feature of syphilitic ulcer is the main symptom which helps to differentiate between syphilis and other genital infections like chancroid,LGV etc.The lymphadenopathy is usually bilateral.This stage is known as primary syphilis.

In secondary syphilis, there may be bilaterally symmetrical asymptomatic skin rash on palms and soles which is the most common finding.There may be loss of hair, described as moth eaten alopecia.Arthritis and proteinuria may also be present along with condyloma lata.

In tertiary syphilis,syphilitic gumma is present.This is the phase where syphilis affects the nervous system.Neurosyphilis has two components, general paresis and tabes dorsalis.

Argyll Robertson’s pupil is another feature of syphilis.In this condition, accomodation reflex is present, but pupillary reflex is absent.

Diagnosis of syphilis

There are several tests to diagnose syphilis.They are TPHA,VDRL,TPA etc.VDRL is used for the prognosis of syphilis.

Treatment of syphilis

Penicillin is the drug of choice for the treatment of syphilis.

Types of human herpes viruses and associated diseases.

Herpes simplex virus

HHV 1- Herpes simplex virus type 1

HHV 2 – Herpes simplex virus type 2

HHV 3- Varicella Zoster virus

HHV 4 -Epstein Barr virus

HHV 5 – Cytomegalo virus

HHV 6- Human B cell lymphotropic virus

HHV 7 -RK virus

HHV 8 -Kaposi virus

Diseases associated with Herpes virus family.

HSV 1 – Usually causes lesions in and around mouth,Most common cause of sporadic encephalitis

HSV 2- Cause lesions in genital area, cause meningitis

HHV 6 causes Exanthem subitum/Roseola infantum also known as sixth disease.

HHV 8 is associated with Kaposi sarcoma and multicentric Castleman disease.

Also see diseases named first disease to sixth disease under exanthematous diseases..

Different types of pelvis and associated conditions

Tri radiate pelvis – Rickets,pagets disease

Beaked pelvis -Osteomalacia

Funnel shaped pelvis – Android pelvis

Rachitic pelvis – Rickets

Nageles pelvis- One ala absent

Roberts pelvis – Both ala absent

Kyphotic/funnel shaped – TB/Rickets

Findings in congenital,primary, secondary and tertiary syphilis

Congenital syphilis

  1. First sign – Rhinitis/Snuffles
  2. Primary bullous lesions

Primary syphilis

Syphilis lesions on back

Image via Wikipedia

  1. Painless punched out non bleeding indurated ulcer
  2. Painless rubbery lymphadenopathy

Secondary syphilis

  1. Bilaterally symmetrical asymptomatic skin rash on palms and soles-MC finding
  2. Moth eaten alopecia
  3. Condyloma lata
  4. Arthritis and proteinuria

Tertiary syphilis

  1. Syphilitic Gumma
  2. Neuro syphilis – General paresis, tabes dorsalis

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