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PARTIAL FULFILMENT
IN
NCM 107-A
DIAGNOSTIC PROCEDURE
OF
MAGNETIC RESONANCE IMAGING
(MRI)
&
CASE STUDY
ABOUT FILARIASIS
SUBMITTED BY:
SHEILLA MAE R. MOISES
SUBMITTED TO:
AUREA CIELITO BATCHAR, RN, MAN, PHD
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MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI) is one of the newest, and perhaps most
versatile, medical imaging technology available. Doctors can get highly refined
images of the body's interior without surgery using MRI. By using strong magnets
and pulses of radio waves to manipulate the natural magnetic properties in the
body, this technique makes better images of organs and soft tissues than those of
other brain scanning technologies. MRI is particularly useful for imaging the brain
and spine, as well as the soft tissues of joints and the interior structure of bones, as
well as the liver. The entire body is visible with MRI, and the technique poses few
known health risks.
Purpose:
MRI is used to visualize the body to assist doctors in their efforts to diagnose
certain diseases or conditions and to evaluate injuries. For pediatric imaging, MRI
is used for a variety of purposes, including the following:
diagnosing diseases of the central nervous system, including the brain and
spine
detecting musculoskeletal disorders and injuries
identifying complications of infectious diseases, such as those associated
with Lyme disease or acquired immunodeficiency syndrome (AIDS)
imaging the cardiovascular system
detecting congenital heart defects in neonates
determining the stage of certain types of cancer
evaluating bone marrow disease
assessing blood vessels in the brain for stroke and other abnormalities assisting in the planning of surgery and cancer treatment
evaluating the urinary tract
MRI provides images with excellent contrast that allow clinicians to clearly see
details of soft tissue, bone, joints, and ligaments. MRI angiography is an imaging
technique used to evaluate the blood vessels, for example, to detect aneurysms or
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cardiovascular problems. Because MRI does not use ionizing radiation to produce
images, like x ray and CT, it is often the examination of choice for pediatric
imaging and for imaging the male and female reproductive systems, pelvis andhips, and urinary tract and bladder.
MRI can also be used to evaluate brain function for assessing language, senses,
neurologic disorders, and pain . This technique, called functional MRI, involves
rapid imaging to display changes in the brain's blood flow in response to tasks or
visual and auditory stimuli. Functional MRI is being researched to image
neurologic disorders, such as attention deficit hyperactivity disorder (ADHD),
delayed cognitive development , and epilepsy.
MRI spectroscopy is another emerging imaging technique for evaluating pediatric
brain disorders. In MRI spectroscopy, chemicals in the brain are measured and
brain tissue is imaged. This technique is being investigated to evaluate traumaticbrain injury, speech delay, creatine deficiency syndromes, and mood disorders in
young children.
Interventional and intraoperative MRI is another developing field that involves
performing interventional procedures, primarily brain surgeries, using a specially
designed MRI unit in an operating room.
PREPARATION
You may be asked to wear a gown during the exam or you may be allowed to wearyour own clothing if it is loose-fitting and has no metal fasteners.
Guidelines about eating and drinking before an MRI exam vary with the specific
exam and also with the facility. For some types of exams, you will be asked to fast
for 8-12 hours. Unless you are told otherwise, you may follow your regular dailyroutine and take medications as usual.
Some MRI examinations may require the patient to swallow contrast material or
receive an injection of contrast into the bloodstream. The radiologist or
technologist may ask if you have allergies of any kind, such as allergy to iodine or
x-ray contrast material, drugs, food, the environment, or asthma. However, the
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contrast material most commonly used for an MRI exam, called gadolinium, doesnot contain iodine and is less likely to cause side effects or an allergic reaction.
The radiologist should also know if you have any serious health problems or if you
have recently had surgery. Some conditions, such as severe kidney disease may
prevent you from being given contrast material for an MRI. If there is a history of
kidney disease, it may be necessary to perform a blood test to determine whether
the kidneys are functioning adequately.
Women should always inform their physician or technologist if there is any
possibility that they are pregnant. MRI has been used for scanning patients since
the 1980s with no reports of any ill effects on pregnant women or their babies.
However, because the baby will be in a strong magnetic field, pregnant women
should not have this exam unless the potential benefit from the MRI exam is
assumed to outweigh the potential risks. See the Safety page for more informationabout pregnancy and MRI.
If you have claustrophobia (fear of enclosed spaces) or anxiety, you may want to
ask your physician for a prescription for a mild sedative prior to the scheduledexamination.
Jewelry and other accessories should be left at home if possible, or removed prior
to the MRI scan. Because they can interfere with the magnetic field of the MRI
unit, metal and electronic objects are not allowed in the exam room. These items
include:
jewelry, watches, credit cards and hearing aids, all of which can be
damaged.
pins, hairpins, metal zippers and similar metallic items, which can distort
MRI images.
removable dental work.
pens, pocketknives and eyeglasses.
body piercings.
In most cases, an MRI exam is safe for patients with metal implants, except for afew types. People with the following implants cannot be scanned and should not
enter the MRI scanning area unless explicitly instructed to do so by a radiologist ortechnologist who is aware of the presence of any of the following:
internal (implanted) defibrillator or pacemaker
cochlear (ear) implant
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some types of clips used on brain aneurysms
You should tell the technologist if you have medical or electronic devices in your
body, because they may interfere with the exam or potentially pose a risk,
depending on their nature and the strength of the MRI magnet. Examples includebut are not limited to:
artificial heart valves
implanted drug infusion ports
implanted electronic device, including a cardiac pacemaker
artificial limbs or metallic joint prostheses
implanted nerve stimulators
metal pins, screws, plates, stents or surgical staples
In general, metal objects used in orthopedic surgery pose no risk during MRI.However, a recently placed artificial joint may require the use of another imaging
procedure. If there is any question of their presence, an x-ray may be taken todetect the presence of and identify any metal objects.
Patients who might have metal objects in certain parts of their bodies may also
require an x-ray prior to an MRI. You should notify the technologist or radiologist
of any shrapnel, bullets, or other pieces of metal which may be present in your
body due to accidents. Dyes used in tattoos may contain iron and could heat up
during MRI, but this is rarely a problem. Tooth fillings and braces usually are not
affected by the magnetic field but they may distort images of the facial area orbrain, so the radiologist should be aware of them.
Infants and young children usually require sedation to complete an MRI exam
without moving. Moderate and conscious sedation can be provided at most
facilities. A physician or nurse specializing in the administration of sedation to
children will be available during the exam to ensure your child's safety while under
the effects of sedation. You will be given special instructions how to prepare your
child for the sedation.
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Nursing Interventions for MRI
1. Provide patient with comfort measures as needed.
2. Tell the patient to resume his normal diet and activities unless otherwise
indicated.3. Monitor vital signs.
4. Monitor the patient for orthostatic hypotension. Assess vital signs before and
after testing
5. Remove any metal items
6. Request a lead apron to shield a fetus or vulnerable body parts
7. Determine if the client is allergic to iodine
8. Know location of emergency equipment
9. Schedule iodine studies before the barium
10. Encourage large amounts of fluid to clear iodine
11. Check on bowel elimination for 2 days after barium studies
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PICTURES OF MAGNETIC RESONANCE IMAGING
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INTRODUCTION
Filiariasis is the name for a group of tropical diseases caused by various thread-likeparasitic round worms (nematodes) and their larvae. The larvae transmit the
disease to humans through a mosquito bite. Filariasis is characterized by fever,
chills, headache, and skin lesions in the early stages and, if untreated, can progress
to include gross enlargement of the limbs and genitalia in a condition called
elephantiasis.
Approximately 170 million people in the tropical and subtropical areas of southeast
Asia, South America, Africa, and the islands of the Pacific are affected by this
debilitating parasitic disease. While filariasis is rarely fatal, it is the second leading
cause of permanent and long-term disability in the world. The World Health
Organization (WHO) has named filariasis one of only six "potentially eradicable"infectious diseases and has embarked upon a 20-year campaign to eradicate the
disease.
In all cases, a mosquito first bites an infected individual then bites another
uninfected individual, transferring some of the worm larvae to the new host. Once
within the body, the larvae migrate to a particular part of the body and mature to
adult worms. Filariasis is classified into three distinct types according to the part of
the body that becomes infected: lymphatic filariasis affects the circulatory system
that moves tissue fluid and immune cells (lymphatic system); subcutaneous
filariasis infects the areas beneath the skin and whites of the eye; and serous cavityfilariasis infects body cavities but does not cause disease. Several different types of
worms can be responsible for each type of filariasis, but the most common species
include the following: Wucheria bancrofti, Brugia malayi (lymphatic filariasis),
Onchocerca volvulus, Loa loa, Mansonella streptocerca, Dracunculus medinensis
(subcutaneous filariasis), Mansonella pustans, and Mansonella ozzardi (serous
cavity filariasis).
The two most common types of the disease are Bancroftian and Malayan filariasis,
both forms of lymphatic filariasis. The Bancroftian variety is found throughout
Africa, southern and southeastern Asia, the Pacific islands, and the tropical and
subtropical regions of South America and the Caribbean. Malayan filariasis occursonly in southern and southeastern Asia. Filariasis is occasionally found in the
United States, especially among immigrants from the Caribbean and Pacific
islands.
A larvae matures into an adult worm within six months to one year and can live
between four and six years. Each female worm can produce millions of larvae, and
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these larvae only appear in the bloodstream at night, when they may be
transmitted, via an insect bite, to another host. A single bite is usually not enough
to acquire an infection, therefore, short-term travelers are usually safe. A series of
multiple bites over a period of time is required to establish an infection. As a result,
those individuals who are regularly active outdoors at night and those who spend
more time in remote jungle areas are at an increased risk of contracting the
filariasis infection.
Causes and symptoms
In cases of lymphatic filariasis, the most common form of the disease, the
disease is caused by the adult worms actually living in the lymphatic vessels near
the lymph nodes where they distort the vessels and cause local inflammation. In
advanced stages, the worms can actually obstruct the vessels, causing the
surrounding tissue to become enlarged. In Bancroftian filariasis, the legs and
genitals are most often involved, while the Malayan variety affects the legs below
the knees. Repeated episodes of inflammation lead to blockages of the lymphatic
system, especially in the genitals and legs. This causes the affected area to become
grossly enlarged, with thickened, coarse skin, leading to a condition called
elephantiasis.In conjunctiva filariasis, the worms' larvae migrate to the eye and can sometimes
be seen moving beneath the skin or beneath the white part of the eye (conjunctiva).
If untreated, this disease can cause a type of blindness known as onchocerciasis.
Symptoms vary, depending on what type of parasitic worm has caused the
infection, but all infections usually begin with chills, headache, and fever between
three months and one year after the insect bite. There may also be swelling,
redness, and pain in the arms, legs, or scrotum. Areas of pus (abscesses) may
appear as a result of dying worms or a secondary bacterial infection.
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Pathophysiology
The filarial life cycle, like that of all nematodes, consists of 5 developmental orlarval stages in a vertebral host and an arthropod intermediate host and vector.
Adult female worms produce thousands of first-stage larvae or microfilariae that
are ingested by a feeding insect vector. Some microfilariae have a unique daily
circadian periodicity in the peripheral circulation. The arthropod vectors,
mosquitoes and flies, also have a circadian rhythm in which they obtain blood
meals. The highest concentration of microfilariae usually occurs when the local
vector is feeding most actively.
Filariasis. This figure displays the life cycle of Wuchereria bancrofti inhumans and mosquito vectors (ie, Aedes, Anopheles, Culex, Mansonia species).
Life cycles of other lymphatic nematodes (ie, Brugia malayi, Brugia timori) are
identical, while the life cycles for other filariae differ in the body location of adult
worms, the microfilariae present, and the arthropod intermediate hosts and vectors.
Microfilariae then undergo two developmental changes in the insect. Third-stage
larvae then are inoculated back into the vertebral host during the act of feeding for
the final two stages of development. These larvae travel through the dermis and
enter regional lymphatic vessels. During the next 9 months, these develop intomature worms (20-100 mm in length). An average parasite can survive for about 5
years.
The prepatent period is defined as the interval between a vector bite and the
appearance of microfilaria in blood, with an estimated duration of about 12
months.
The following factors affect the pathogenesis of filariasis:
The quantity of accumulating adult worm antigen in the lymphatics[5]
The duration and level of exposure to infective insect bites[6]
The number of secondary bacterial and fungal infections[5]
The degree of host immune response[7]
Filarial infection generates significant inflammatory immune responses that
participate in the development of symptomatic lymphatic obstruction. Increased
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levels of immunoglobulin E (IgE) and immunoglobulin G4 (IgG4) secondary to
antigenic (from dead worms) stimulation of Th2-type immune response have been
demonstrated.
Studies have shown that there is a familial tendency to lymphatic obstruction,
providing support for the hypothesis that host genes influence lymphedema
susceptibility.[8]
Prenatal exposure seems to be an important determinant in
conferring greater immune tolerance to parasite antigen.[9]
Thus, individuals from
endemic areas are often asymptomatic until late in disease when they have high
worm burden, whereas nonimmune expatriates tend to have brisk immune
responses and more severe early clinical symptoms, even in light infections.
Recent studies have shown that lymphatic filarial parasites contain rickettsialike
Wolbachia endosymbiotic bacteria. This association has been recognized as
contributing to the inflammatory reaction seen in filariasis.[10]
Identification of microfilariae by microscopic examination is the most practical
diagnostic procedure. Examination of blood samples will allow identification of
microfilariae of Wuchereria bancrofti, Brugia malayi and Brugia timori. It is
important to time the blood collection with the known periodicity of the
microfilariae. The blood sample can be a thick smear, stained with Giemsa or
hematoxylin and eosin.
Diagnosis of other filariasis diseases
Examination of blood samples will allow identification of microfilariae of
Loa loa, Mansonella perstans, and M. ozzardi.
Examination of skin snips will identify microfilariae of Onchocerca volvulus
and Mansonella streptocerca. Skin snips can be obtained using a corneal-
scleral punch, or more simply a scalpel and needle. The sample must be
allowed to incubate for 30 minutes to 2 hours in saline or culture medium,
and then examined for microfilariae that would have migrated from the
tissue to the liquid phase of the specimen
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Treatment
Either ivermectin, albendazole, or diethylcarbamazine is used to treat a filariasis
infection by eliminating the larvae, impairing the adult worms' ability to reproduce,
and by actually killing adult worms. Unfortunately, much of the tissue damage
may not be reversible. The medication is started at low doses to prevent reactions
caused by large numbers of dying parasites.
While effective, the medications can cause severe side effects in up to 70% of
patients as a result either of the drug itself or the massive death of parasites in the
blood. Diethylcarbamazine, for example, can cause severe allergic reactions and
the formation of pusfilled sores (abscesses). These side effects can be controlled
using antihistamines and anti-inflammatory drugs (corticosteroids). Rarely,
treatment with diethylcarbamazine in someone with very high levels of parasite
infection may lead to a fatal inflammation of the brain (encephalitis). In this case,
the fever is followed by headache and confusion, then stupor and coma causedwhen massive numbers of larvae and parasites die. Other common drug reactions
include dizziness, weakness, and nausea.
Symptoms caused by the death of the parasites include fever, headache, muscle
pain, abdominal pain, nausea and vomiting, weakness, dizziness, lethargy, and
asthma. Reactions usually begin within two days of starting treatment and may last
between two and four days.
No treatment can reverse elephantiasis. Surgery may be used to remove surplus
tissue and provide a way to drain the fluid around the damaged lymphatic vessels.
Surgery may also be used to ease massive enlargement of the scrotum.
Elephantiasis of the legs can also be helped by elevating the legs and providing
support with elastic bandages.