Tropical Doctor

One hundred children (consecutive) with positive blood culture for Salmonella typhi were studied for clinical profile and complications. The common clinical features were fever (100%), vomiting (58%), abdominal pain (48%), cough (22%) and loose stools (14%) and the Widal test was positive in 75% patients. Eighty per cent of the salmonella isolates were resistant to amoxycillin, chloramphenicol and co-trimoxazole drugs, but all were sensitive to ciprofloxacin and ceftriaxone. Forty patients developed complications: encephalopathy (18), melaena (12), haematemesis (10), epistaxis (4), hepatitis (4), acalculous cholecystitis (4), bowel perforation (3) and nephritis (2). Complications were more frequent in children with multidrug-resistant typhoid. The final antibiotic required to render the children afebrile included ciprofloxacin (80), ceftriaxone, amoxycillin (4), chloramphenicol (4), amoxycillin and gentamicin (4), amoxycillin with chloramphenicol (2), and furazolidone (2). The defervesence time was least with ceftriaxone and greatest with amoxycillin. All the affected children made a complete recovery.

The prevalence of Legionella pneumophila causing community-acquired pneumonia (CAP) in patients who were admitted to hospital was investigated. Between April 1997 and December 1998, 60 patients admitted to the All India Institute of Medical Sciences with CAP, were included in the study. Aetiological diagnosis was based on the results of routine microbiological blood culture for bacteria and serological test by enzyme-linked immunosorbent assay (ELISA) for L. pneumophila serogroup 1–7. Eight (13%) patients had a conventional bacterial aetiology and nine (15%) had serological evidence of recent infection with L. pneumophila. Legionella pneumophila may be an important cause of CAP in adults in developing countries. Empiric antimicrobial treatment should include a combination of agents to cover both atypical agents and bacterial pathogens.

Suicide is an important cause of death in developing and developed countries. Because of its multifactorial nature it is often difficult to study. Suicide also brings with it social stigma and, in some cases, legal repercussions. Suicide is generally underreported and, therefore, services directed at decreasing its incidence are not given priority. This retrospective study of suicide deaths over a period of 2 years in the Lalitpur district of rural Nepal demonstrates the complicated issues involved, and suggests some appropriate strategies for addressing suicide risk.

One hundred and sixty eight febrile adult outpatients were investigated at St Francis Designated District Hospital in Ifakara, a holoendemic area in Tanzania. We wanted to assess the potential anamnestic and clinical risk indicators for malaria and to establish a rational strategy for malaria management. Blood slide investigations showed that 14% of all patients were positive for P. falciparum. All the positive cases were found during the rainy season. No reliable criteria for malaria were found in the history taking and physical examinations. Signs and symptoms of respiratory tract infection such as difficulties during breathing, sore throat, chest pain, cough, pathological findings in lung auscultation and combinations of these were negatively associated with malaria parasitaemia. The same was true for lymph node swelling and a clinical diagnosis other than malaria. Quality control of blood slide results from the hospital revealed a sensitivity of 55%, a specificity of 72%, and positive and negative predictive values of 24% and 91%. The main recommendations for malaria management in adults were to improve the quality of blood slide examinations and to use a different diagnostic strategy during the dry and rainy seasons. During the dry season blood slides of febrile adult patients should only be performed if there is a suspicion of malaria and antimalarial drugs should only be administered if blood slide results are positive. During the rainy season all febrile adults without obvious cause of fever other than malaria should be treated with antimalarials without previous blood slide examination.

The features of measles presenting at the University of Calabar Teaching Hospital, in south-eastern Nigeria between January 1992 to December 1996, were compared with those of a previous period (January 1984 to December 1987) in the same institution. The aim was to detect any changes in trends, morbidity and mortality from the infection in this environment. There were only 36 cases (7.2 per year) in the current period compared with 436 (109 per year) in the previous period (χ²=48.4, P< 0.001). There were also highly significant falls in the incidence of malnutrition and bronchopneumonia (P<0.05) in the current period. Notably, there were no cases of dehydration or keratomalacia in the current period. The case fatality rate was 2.8% compared with 20.0% in the previous period (P< 0.02). These unprecedented changes in the incidence, morbidity and mortality from measles are attributed to the continuing Expanded Programme on Immunization, oral rehydration therapy, appropriate nutritional management and vitamin A prophylaxis. With maintenance and strengthening of these strategies, the elimination of measles and measles deaths in the near future is feasible in this environment.

While poisonings from developed nations have been extensively described there is a dearth of information on poisoning in societies which have different patterns of daily life, customs, products and beliefs. This study surveys childhood non-drug poisoning, the circumstances of exposure, prevalence demographics and products as well as therapy. The commonest poisoning is kerosene (paraffin), incidence was 2/1000 and the age at highest risk is 12–24 months. Often cases were inappropriately managed at home before arriving at the hospital.

Chloroquine-induced itch in black-skinned African malaria patients is common and frequently leads to poor compliance or treatment defaulting. To assess the frequency and severity of chloroquine-induced pruritus in an Asian population, we reviewed case records of 1189 Plasmodium vivax malaria patients treated with chloroquine (25 mg/kg over 3days) at the Bangkok Hospital for Tropical Diseases from 1992 through 1997. The majority of patients were Thais or ethnic Burmese (light brown skin), referred from the western border of Thailand. Overall, there were 23 patients (1.9%) with complaints of pruritus during chloroquine therapy. Of these, 12 (52%) had palm and sole involvement, eight (35%) had generalized pruritus including the palms and soles, and three (13%) had palm itching only. One patient developed pruritus on the palms and soles on two consecutive admissions. The pruritus did not interfere with daily activity, was reduced in intensity by anti-histamine therapy, and did not affect the patient's willingness to complete the chloroquine regimen. Therapeutic responses in the 23 patients with chloroquine itch was similar to those without itch. Among the itch patients, there was no association with gender or level of parasitaemias. Our findings indicate that the frequency of chloroquine-induced pruritus in Asian patients treated with chloroquine for P. vivax malaria is low in comparison with black-skinned Africans. This may be related to pharmacogenetic factors, the infective Plasmodium species, drug metabolism or drug-parasite interactions, or a lower affinity of chloroquine for less pigmented skin.

Twenty-seven children aged 18 years and under with homozygous sickle-cell disease had open cholecystectomy for symptomatic gallstones over the 12-year period 1985–1997. Emergency procedures (done during period of acute exacerbation of symptoms) were performed on 16 patients. Four with haemoglobin levels greater than 1 g/dl below their steady state received a simple blood transfusion preoperatively designed to raise haemoglobin levels to 10 g/dl. All had acute or acute on chronic cholecystitis based on histological examination of gallbladder specimens.

Twelve had common bile duct stones. In two patients calculi were missed intraoperatively but these subsequently passed into the duodenum after a period saline irrigation via an in-situ t-tube. Six developed the acute chest syndrome (aetiology not determined) and this progressed to multi system failure and death in one. This high level of postoperative mobility and mortality may in part be due to the high proportion of emergency procedures.

This study was undertaken to assess the healthcare needs of people with tuberculosis (TB) in the rural district of Lubombo in Swaziland, with a view to improving the delivery of healthcare services. Qualitative and quantitative methodologies were used to describe the knowledge, attitudes and behaviour of TB patients, the epidemiology of TB, and the strengths and weaknesses of the current TB control programme.

The incidence of TB is rising rapidly in this rural region of Swaziland. Poor treatment completion rates indicate low levels of knowledge about the importance of compliance with TB treatment among many other factors. If local health services are to cope with future rising demands, then efforts must be made to implement a community-based TB treatment strategy. Key practical steps in establishing such a programme are discussed, and the experience from Lubombo is used to demonstrate the steps in performing a health needs assessment in a developing country.

This is a retrospective analysis of 82 patients undergoing thyroid operations in a general medical practice hospital in sub-Saharan Africa. All patients complained of neck swelling, and in 75% of patients this was the only symptom. Indications for operation included cosmesis in 74%, suspected malignancy in 13%, hyperthyroidism in 7% and pressure symptoms in 5%. Operative complications included recurrent laryngeal nerve injury in two (2.4%), wound haematoma in two (2.4%), wound infection in three (3.6%) and hypoparathyroidism in one (1.2%). There were no deaths and no instances of thyroid storm. Thyromegaly can be operatively managed in a hospital such as ours with a relatively low morbidity rate using conservative gland extirpation techniques. This conservative approach may result in under treatment for thyroid maligancies but should result in a lower incidence of recurrent nerve damage and hypoparathyroidism in the majority of people who undergo thyroidectomy solely for cosmetic indications.

Nasal myiasis is a common disease in tropical and developing countries. The maggots cause extensive necrosis, sloughing and destruction of intranasal tissue and reach to deep and inaccessible areas of the nose and paranasal sinuses. In such a situation removal of maggots is difficult by manual extraction and several sittings are required. To overcome this problem nasal endoscope is being used for removal of maggots under direct vision. In comparing both methods nasal endoscopic procedure is found to be superior to the manual extraction method for removal of maggots. The maggots located in deep and inaccessible area can be approached more easily by endoscopic procedure. The disease is being controlled in shorter time and in few sittings. Thus quick and complete eradication of myiasis is possible before the maggots cause irreparable damage to the intranasal tissues.

Histopathological examination of biopsies from 111 patients with clinically diagnosed leprosy was carried out in order to observe the clinico-histopathological correlation. Clinical diagnosis was based on Ridley and Jopling (R-J) classification and World Health Organization (WHO) classification. The concordance rate between the two clinical classifications was 73.8%. Sections were stained with haematoxylin and eosin (H&E) and Ziehl-Neelsen's (Z-N) stains. The histological classification was as per the R-J criteria. Skin biopsy showed evidence of leprosy in 104 cases (93.69%). Overall concordance was observed in 58.6% (R-J) and 85.6% (WHO classification). The kappa test, when applied, showed significant agreement between clinical and histopathological diagnosis (z=11.775; P<0.001). Individual subtypes showed variable concordance rates — which were again higher using WHO classification. When some of the subtypes were combined, the concordance rate was 83.02% for TT+BT; 72.58% for BT+BB+BL; 73.91% for BL+LL; 80.77% for BL+HL and 100% for LL+HL. (See Introduction for definitions of abbreviations.

The present study highlights the importance of histopathological examination for exact subtyping of leprosy, so as to facilitate the institution of accurate mode of therapy and regular follow-up of patients to prevent undesirable complications.