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Patrons who spent time with their heads underwater with their eyes open were affected. Twelve persons affected in an outbreak Texas, September 1999 reported symptoms that included exhaustion, sore muscles, headache, chills, and fever after attending a conference at a guest ranch. Exposure to a hot tub, defined as either immersion or being near the hot tub, was associated with illness. Although clinical specimens urine, blood, sputum, and throat swabs were tested for organisms, including Leg. No testing for biologic or chemical agents was performed on water samples because the hot tub had already been drained, refilled, and hyperchlorinated before the environmental investigation. During the 1999–2000 reporting period, 15 outbreaks of dermatitis were identified Table 9.

Three of these outbreaks were associated with swimming in freshwater and were assumed to be cercarial dermatitis caused by contact with the larval form cercariae of schistosomes, which are present in freshwater environments. Two of these dermatitis outbreaks occurred in lakes in California that were associated with past cases of cercarial dermatitis. The onset of dermatitis occurred within hours after swimming in the lake and resolved after a limited number of days median days of illness were 2 and 3 days [range: In eight of these outbreaks of dermatitis, specific treatment deficiencies or problems were identified. Outbreaks in Arkansas June 1999, Florida August 2000, Colorado December 1999, and Washington March 2000 were attributed to deficiencies in treatment. The pool and hot tub were on separate filtration systems, and both were used by the majority of persons in the outbreak.

Low levels of free chlorine were found in the pool and hot tub, but the presence of chlorinate isocyanurates chlorine stabilizers might have influenced measured levels of free chlorine. Symptoms were not limited to rash; they included diarrhea, vomiting, nausea, fever, fatigue, muscle aches, joint pain, swollen lymph nodes, and subcutaneous nodules on hands and feet. Because of the severity and range of symptoms, clinical specimens were examined for enteric bacterial and parasitic pathogens as well as Legionella species, Leptospira species, and Entamoeba histolytica but did not test positive for any of these etiologic agents.

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Local injection of a steroid into a previously infected joint is not usually recommended. Musculoskeletal Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation i. This, together with a decrease in the protein matrix of the bone secondary to an increase in protein catabolism, and reduced sex hormone production, may lead to inhibition of bone growth in pediatric patients and the development of osteoporosis at any age.

Special consideration should be given to patients at increased risk of osteoporosis i. The studies do show that relatively high doses of corticosteroids are necessary to demonstrate a significant effect. An acute myopathy has been observed with the use of high doses of corticosteroids, most often occurring in patients with disorders of neuromuscular transmission e.

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