Clinical Cases in Tropical Medicine E-Book

Camilla Rothe

• Publisher: Elsevier
• Year: 2020
• Print ISBN: 9780702078798
• eBook ISBN: 9780702078804
• Edition: 2
• Topic: Medicina
• Subtopic: Malattie infettive

Using an easily accessible, highly templated format, Clinical Cases in Tropical Medicine, 2nd Edition, provides more than 100 realistic scenarios for tropical infectious diseases. Full-color photographs and maps, a convenient question-and-answer presentation, and succinct summary boxes help you identify and understand the tropical diseases you're likely to encounter. This up-to-date 2nd Edition is an excellent resource and study tool for infectious diseases fellows, doctors preparing for exams in tropical medicine, primary care doctors with patients who are global travelers, and global health nurses and practitioners alike.

• Offers realistic scenarios for encountering patients in rural, resource-poor settings, presenting cases as "unknowns, " just as in a real clinic or emergency situation.
• Covers newly emerging diseases such as Zika virus, severe fever with thrombocytopenia syndrome (SFTS), and knowlesi malaria.
• Features topics in migrant medicine of particular importance to clinicians in non-tropical countries, including louse-borne-relapsing fever, spinal brucellosis, and hyperreactive malarial splenomegaly.
• Includes "classic" tropical diseases such as African trypanosomiasis, chagas, leprosy, and yaws.
• Reflects the use of novel diagnostics used in resource-poor settings, as well as developing drug resistance in relevant cases.
• Provides a useful index and map that organize cases geographically, for a targeted approach to study.
• Serves as a companion to Manson's Tropical Diseases, with a reading list at the end of each case referring to the corresponding chapter in the larger text.

1: A 20-Year-Old Woman from Sudan With Fever, Haemorrhage and Shock

Daniel G. Bausch

Clinical Presentation

History

A 20-year-old housewife presents to a hospital in northern Uganda with a 2-day history of fever, severe asthenia, chest and abdominal pain, nausea, vomiting, diarrhoea and slight non-productive cough. The patient is a Sudanese refugee living in a camp in the region. She denies any contact with sick people.

Clinical Findings

The patient is prostrate and semiconscious on admission. Vital signs: temperature 39.6°C, (103.3°F) blood pressure 90/60 mmHg, pulse 90 bpm, and respiratory rate 24 cycles per minute. Physical examination revealed abdominal tenderness, especially in the right upper quadrant, hepatosplenomegaly and bleeding from the gums. The lungs were clear. No rash or lymphadenopathy was noted.

Questions

1. 1. Is the patient’s history and clinical presentation consistent with a haemorrhagic fever (HF) syndrome?
2. 2. What degree of nursing precautions need to be implemented?

Discussion

This patient was seen during an outbreak of Ebola virus disease in northern Uganda, so the diagnosis was strongly suspected. She was admitted to the isolation ward that had been established as part of the international outbreak response. No clinical laboratory data were available because, for biosafety reasons, such testing was suspended. Although it is a reasonable precaution, the suspension of routine testing often causes difficulty in ruling out the many other febrile syndromes in the differential diagnosis and increases mortality from other non-Ebola disease. Fortunately, many clinical laboratory tests can now be safely performed with point-of-care instruments, often brought into a specialized laboratory in the isolation ward, as long as the laboratory personnel are properly trained and equipped.

Answer to Question 1

Is the Patient’s History and Clinical Presentation Consistent with an HF Syndrome?

The clinical presentation is indeed one of classic viral HF. However, most times the diagnosis is not so easy. Although some patients, such as this one, do progress to the classic syndrome with haemorrhage, multiple organ dysfunction syndrome and shock, haemorrhage is not invariably seen (and may even be noted in only a minority of cases with some virus species), and severe and fatal disease may still occur in its absence. The clinical presentation of viral HF is often very non-specific. Furthermore, haemorrhage may be seen in numerous other syndromes, such as complicated malaria, typhoid fever, bacterial gastroenteritis and leptospirosis, which are the primary differential diagnoses, depending on the region.

Answer to Question 2

What Degree of Nursing Precautions Needs to be Implemented?

The spread of Ebola virus between humans is through direct contact with blood or bodily fluids. Secondary attack rates are generally 15% to 20% during outbreaks in Africa, and much lower if proper universal precautions are maintained. Specialized viral HF precautions and personal protective equipment are warranted when there is a confirmed case or high index of suspicion, such as in this case.

The Case Continued. . .

Intravenous fluids, broad-spectrum antibiotics and analgesics were begun on admission. Nevertheless, the patient’s condition rapidly worsened, with subconjunctival haemorrhage, copious bleeding from the mouth, nose and rectum (Figs. 1.1 and 1.2), dyspnoea and hypothermic shock (temperature 36.0°C, blood pressure = unreadable, pulse 150 bpm, respiratory rate 36 cycles per minute). She became comatose and died approximately 24 hours after admission. Laboratory testing at a specialized laboratory established as part of the outbreak response showed positive ELISA antigen and PCR tests for Ebola virus and a negative result for ELISA IgG antibody, confirming the diagnosis of Ebola virus disease.

Fig. 1.1 Oral bleeding in Ebola virus disease. (Bausch, D.G., 2008. Viral hemorrhagic fevers. In: Schlossberg, D. (Ed.), Clinical Infectious Disease. Cambridge University Press, New York. Used with permission. Photo by Bausch, D.)

Fig. 1.2 Rectal bleeding in Ebola virus disease. (Bausch, D.G., 2008. Viral hemorrhagic fevers. In: Schlossberg, D. (Ed.), Clinical Infectious Disease. Cambridge University Press, New York. Used with permission. Photo by Bausch, D.)

Summary box

Filoviral Diseases

Ebola and Marburg virus disease are the two syndromes caused by filoviruses. Microvascular instability with capillary leak and impaired haemostasis, often including disseminated intravascular coagulation, are the pathogenic hallmarks. There are four known pathogenic species of Ebola and one of Marburg virus, with relatively consistent case fatality associated with each species, ranging from 25% to 85%. Ebola and Marburg diseases are generally indistinguishable, both with non-specific presentations typically including fever, headache, asthenia, myalgias, abdominal pain, nausea, vomiting and diarrhoea. Conjunctival injection and subconjunctival haemorrhage are common. A fleeting maculopapular rash is occasionally seen. Typical laboratory findings include mild lymphopenia and thrombocytopenia, and elevated hepatic transaminases, with AST > ALT. Leucocytosis may be seen in late stages. The differential diagnosis is extremely broad, including almost all febrile diseases common in the tropics.

Ebola and Marburg virus diseases are endemic in sub-Saharan Africa, with Ebola virus typically found in tropical rainforests in the central and western parts of the continent and Marburg virus in the drier forest or savannah in the east. Evidence strongly implicates fruit bats as the filovirus reservoir, especially the Egyptian fruit bat (Rousettus aegyptiacus) as the reservoir for Marburg virus. Human infection likely occurs from inadvertent exposure to infected bat excreta or saliva. Male-to-female sexual transmission may occur months after infection because of the virus’s persistence in the semen, although these events are relatively rare.

Miners, spelunkers, forestry workers and others with exposure in environments typically inhabited by bats are at risk, especially for Marburg virus disease. Non-human primates, especially gorillas and chimpanzees, and other wild animals may serve as intermediate hosts that transmit filoviruses to humans through contact with their blood and bodily fluids, usually associated with hunting and butchering. These wild animals are presumably also infected by exposure to bats and usually develop severe and fatal disease similar to human viral HF. Most outbreaks are thought to result from a single or very few human introductions from a zoonotic source followed by nosocomial amplification through person-to-person transmission in a setting of inadequate universal precautions, usually in rural areas of countries where civil unrest has decimated the healthcare infrastructure.

Because symptoms are generally non-specific and laboratory testing is not widely available, viral HF outbreaks are usually recognized only if a cluster of cases occurs, especially when healthcare workers are involved. Having been into caves or mines, and direct or indirect contact with wild animals or people with suspected viral HF, are key diagnostic clues, but these are not uniformly present. Outside consultation with experts in the field and testing of suspected cases should be rapidly undertaken and public health authorities must be alerted.

Contact tracing should be undertaken to identify all persons with direct unprotected exposure with the case patient, with surveillance of contacts for fever for 21 days (the maximum incubation period for Ebola and Marburg virus diseases). Any contact developing fever or showing other signs of viral HF should immediately be isolated and tested.

Treatment is supportive. Antimalarials and broad-spectrum antibiotics should be given until the diagnosis of viral HF is confirmed. Preliminary results from a clinical trial of experimental compounds conducted during an outbreak in the Democratic Republic of the Congo show very promising results, reducing case fatality to as low as 10% if treatment is administered early in the course of disease. Similarly, a clinical trial of an Ebola vaccine in the Democratic Republic of the Congo and during the massive 2013 to 2016 outbreak in West Africa showed protective efficacy of over 90%.

Further Reading

1 Blumberg L., Enria D., Bausch D.G. Viral haemorrhagic fe...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Foreword
• Preface
• List of Contributors
• Acknowledgements
• 1: A 20-Year-Old Woman from Sudan With Fever, Haemorrhage and Shock
• 2: A 7-Year-Old Girl from Peru With a Chronic Skin Ulcer
• 3: A 26-Year-Old Woman from Malawi with Headache, Confusion and Unilateral Ptosis
• 4: A 4-Year-Old Girl from Uganda in a Coma
• 5: A 4-Year-Old Boy from Laos With a Lesion of the Lip and Cheek
• 6: A 36-Year-Old Male Traveller Returning from Botswana With a Creeping Eruption
• 7: A 28-Year-Old Male Fisherman from Malawi With Shortness of Breath
• 8: A 26-Year-Old Female Traveller Returning from Ghana With a Boil on the Leg
• 9: A 52-Year-Old Man from Vietnam With Evolving Shock
• 10: A 55-Year-Old Indigenous Woman from Australia With a Widespread Exfoliating Rash and Sepsis
• 11: A 45-Year-Old Male Security Guard from Malawi With Difficulties in Walking and Back Pain
• 12: A 29-Year-Old Man from The Gambia With Genital Ulceration
• 13: A 16-Year-Old Girl from Malawi With Fever and Abdominal Pain
• 14: A 22-Year-Old Woman from Bangladesh With Profuse Watery Diarrhoea
• 15: A 3-Year-Old Boy from Laos With Right Suppurative Parotitis
• 16: A 25-Year-Old Female School Teacher from Malawi With Abrupt Onset of Fever and Confusion
• 17: A 34-Year-Old Man from Thailand With Fever and a Papular Rash
• 18: A 56-Year-Old Man Returning from a Trip to Thailand With Eosinophilia
• 19: A 40-Year-Old Man from Togo With Subcutaneous Nodules and Corneal Opacities
• 20: A 43-Year-Old Male Traveller Returning from Mozambique With Fever and Eosinophilia
• 21: A 35-Year-Old American Man With Fatigue and a Neck Lesion
• 22: 32-Year-Old Woman from Nigeria With Jaundice and Confusion
• 23: A 31-Year-Old HIV-Positive Business Traveller With Cough, Shortness of Breath and Night Sweats
• 24: A 14-Year-Old Boy from Rural Tanzania With Difficulty in Walking
• 25: A 72-Year-Old Male Farmer from Laos With Extensive Skin Lesions on the Lower Leg
• 26: A 14-Year-Old Boy from Malawi Who Has Been Bitten by a Snake
• 27: A 16-Year-Old Boy from Sri Lanka With Fever, Jaundice and Renal Failure
• 28: A 67-Year-Old Female Expatriate Living in Cameroon With Eosinophilia and Pericarditis
• 29: A 35-Year-Old Woman from Malawi With Fever and Severe Anaemia
• 30: A 12-Year-Old Boy from Rural Kenya With Painful Eyes
• 31: A 6-Year-Old Boy from Malawi With Fever, Cough and Impaired Consciousness
• 32: A 44-Year-Old Male Farmer from Laos With Diabetes and a Back Abscess
• 33: A 53-Year-Old Man from Malawi With a Chronic Cough
• 34: A 35-Year-Old Male Farmer from Peru With a Chronic Ulcer and Multiple Nodular Lesions on the Arm
• 35: A 32-Year-Old Woman from Malawi With Headache and Blurred Vision
• 36: A 23-Year-Old Farmer from Myanmar With Unilateral Scrotal Swelling
• 37: A 29-Year-Old Woman from Malawi With Confusion, Diarrhoea and a Skin Rash
• 38: A 24-Year-Old Female Globetrotter With Strange Sensations in the Right Side of Her Body
• 39: A 30-Year-Old Male Chinese Trader With Fever in Laos
• 40: A 62-Year-Old Woman from Ethiopia With Difficulty Eating
• 41: A 7-Year-Old Girl from West Africa With Two Skin Ulcers and a Contracture of Her Right Wrist
• 42: A 41-Year-Old Male Traveller Returning from Australia With Itchy Eruptions on His Thighs
• 43: A 35-Year-Old Malawian Woman With a Painful Ocular Tumour
• 44: A 7-Year-Old Girl from South Sudan With Undulating Fever
• 45: A 2-Month-Old Girl from Laos With Dyspnoea, Cyanosis and Irritability
• 46: A 45-Year-Old Man from Sri Lanka With Fever and Right Hypochondrial Pain
• 47: A 32-Year-Old Man from Malawi With a Painfully Swollen Neck
• 48: A 31-Year-Old Woman from Tanzania With Acute Flaccid Paraplegia
• 49: A 33-Year-Old Male Traveller to India With Diarrhoea and Flatulence for Two Weeks
• 50: A 24-Year-Old Man of Turkish Origin With Jaundice and Cystic Liver Lesions
• 51: A 34-Year-Old HIV-Positive Woman from Malawi With Slowly Progressive Half-Sided Weakness
• 52: A 56-Year-Old Man from Peru With Prolonged Fever and Severe Anaemia
• 53: A 24-Year-Old Woman from Uganda With Fever and Shock
• 54: A 52-Year-Old Male Safari Tourist Returning from South Africa With Fever and a Skin Lesion
• 55: A 40-Year-Old Male Farmer from Peru With Chronic Cough and Weight Loss
• 56: A 21-Year-Old Pregnant Woman from The Gambia With a Rash
• 57: A 37-Year-Old Woman from Malawi With Haematemesis
• 58: A 25-Year-Old Woman from Egypt With Severe Chronic Diarrhoea and Malabsorption
• 59: A 24-Year-Old Man from Malawi With Skin Lesions and Breathlessness
• 60: A 6-Year-Old Boy from Malawi With Proptosis of the Left Eye
• 61: A 48-Year-Old Woman from Thailand With Fever and Disseminated Cutaneous Abscesses
• 62: A 28-Year-Old Man from Ghana With a Chronic Ulcer on His Ankle
• 63: A 38-Year-Old European Expatriate Living in Malawi With Difficulty Passing Urine
• 64: A 40-Year-Old Woman from Thailand and Her Brother-in-Law With Severe Headache
• 65: A 4-Year-Old Girl from Bolivia With a Dark Nodule on Her Toe
• 66: A 32-Year-Old Man from Malawi With Pain in the Right Upper Abdomen and a Feeling of Faintness
• 67: A 24-Year-Old Woman from the Peruvian Andes With Fever and Abdominal Pain
• 68: A 31-Year-Old Woman from Malawi With a Generalized Mucocutaneous Rash
• 69: A 22-Year-Old Male Farmer from Rural Ethiopia With Difficulty Walking
• 70: A 58-Year-Old Woman from Sri Lanka With Fever, Deafness and Confusion
• 71: A 71-Year-Old Man from Japan With Eosinophilia and a Nodular Lesion in the Lung
• 72: A 4-Year-Old Boy from Mozambique With Severe Oedema and Skin Lesions
• 73: A 21-Year-Old Male Migrant from Rural Mali With Massive Splenomegaly
• 74: A 28-Year-Old Woman from Sierra Leone With Fever and Conjunctivitis
• 75: A 25-Year-Old Woman from Zambia With a New-Onset Seizure
• 76: A 55-Year Old Woman from Turkey With Fever of Unknown Origin
• 77: A 51-Year-Old Female Traveller Returning from Central America With Conjunctivitis, Rash and Peripheral Oedema
• 78: A 42-Year-Old British Man Living in Malawi With Anaphylactic Shock
• 79: A 34-Year-Old Male Immigrant from Peru With Chronic Diarrhoea and Severe Weight Loss
• 80: A 62-Year-Old Man from Thailand With a Liver Mass
• 81: A 33-Year-Old Refugee from Afghanistan With Recurrent Fever and Back Pain
• 82: A 31-Year-Old Man from Guatemala With Acute Weakness and Numbness of the Leg
• 83: An 18-Year-Old Man from India With a Pale Patch on His Right Upper Limb
• 84: A 64-Year-Old Japanese Man With Generalized Tonic-Clonic Seizures
• 85: A 55-Year-Old Female Pig Farmer from Vietnam With Fever and Impaired Consciousness
• 86: A 14-Year-Old Girl in the Solomon Islands With a Non-Healing Leg Ulcer
• 87: A 27-Year-Old Male Traveller Returning from the Peruvian Amazon With Persisting Polyarthralgias
• 88: A 74-Year-Old Man from Japan With Fever, Nausea and Drowsiness
• 89: A 30-Year-Old Woman from Bolivia With Exertional Dyspnoea
• 90: A 55-Year-Old Couple Both Returning from Chile and Argentina With Acute Respiratory Distress Syndrome
• 91: A 20-Year-Old Male from India With Fever and Quadriparesis
• 92: A 42-Year-Old Traveller Returning from Thailand With Fever and Thrombocytopenia
• 93: A 35-Year-Old Male Logger from Peru With Fever, Jaundice and Bleeding
• 94: A 20-Year-Old Woman from the Democratic Republic of the Congo With Fever and a Vesiculopustular Skin Rash
• 95: A 42-Year-Old Male Refugee from the Democratic Republic of the Congo With Progressive Depression
• 96: A 19-Year-Old Boy from India With Drooping, Diplopia and Dysphagia
• 97: An 87-Year-Old Japanese Man With a Serpiginous Erythema on the Right Thigh
• 98: A 17-Year-Old Boy from South India With a Fever and a Reduced Level of Consciousness
• 99: A 43-Year-Old Male Traveller Returning from the Australian Outback with Fever, Joint Pains and a Rash
• 100: A 25-Year-Old Man from Ethiopia With a Nodular Rash
• 101: A 46-Year-Old Male Traveller with Chronic Cough After a Trip to South America
• 102: A 16-Year-Old Male Refugee from Somalia With High Fever and Slurred Speech
• 103: A 43-Year-Old Man from Peru With a Chronic Fistulating Foot Lesion
• Index