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Usually caused by staphylococcal exotoxin associated with high-absorbency tampon use. Strep. pyogenes can also cause it. The rare syndrome usually begins within 5 days of the onset of the period.

Clinical features include sudden onset fever, vomiting and diarrhoea, muscle aches and pains, skin erythema, hypotension progressing to confusion, stupor and sometimes death.

Management

Active treatment depends on the severity of the illness. Cultures should be taken from the vagina, cervix, perineum and nasopharynx. The patient should be referred to a major centre if ‘shock’ develops. Otherwise the vagina must be emptied, ensuring there is not a forgotten tampon, cleaned with a povidone–iodine solution tds for 2 d, and di(flu)cloxacillin or vancomycin antibiotics administered for 8–12 d.

Blocked nasolacrimal duct

• If conjunctivitis present: neosporin or chloramphenicol eye drops

• Perform regular massage from inner canthus to base of nose (teach mother) at least twice daily

• If persistent in infant: requires nasolacrimal probing at 4–6 mths—otherwise leave to 6 mths or more as it may resolve

Babies usually cut their teeth from 6 mths until 2–3 yrs with discomfort usually caused by the molars (ages 1–3).

Precautions: exclude other possible causes of irritability in a teething child (e.g. UTI, meningitis, otitis media). Teething doesn't cause fever.

Treatment

• Reassure parents that the problem will soon settle.

Chewing soothing methods

• Teething ring (kept cold in the refrigerator) or

• Baby can chew on a clean, cold, lightly moistened facewasher (a piece of apple can be placed in the facewasher) or

• Parent can massage gum with forefinger wrapped in a soft cloth or gauze pad (Oro-Sed gel can be massaged into gums every 3 h if extremely troublesome)

Refer to the techniques on treatment of TMJ dysfunction. Most effective and simplest method is placing a piece of soft wood (e.g. carpenter's pencil) firmly against back molars and biting rhythmically on the object with a grinding movement for 2–3 mins at least 3 times a day.

A mass that is part of the testis, and solid, is likely to be a tumour.

Clinical features

Golden rules

• All solid scrotal lumps are malignant until proved otherwise and must be surgically explored.

• Beware of hydroceles in young adults.

• Investigate with US.

• Avoid scrotal needling because of risk of tumour implantation in scrotal wall. For surgery, orchidectomy is through an inguinal incision.

Prognosis is good for most testicular tumours with 5-yr cure rates of 90–95%. Refer early to specialist centre.

Up to 20% of patients have no observable entry wound.

Clinical features

• Prodrome: fever, malaise, headache

• Trismus (patient cannot close mouth)

• Risus sardonicus (a grin-like effect from hypertonic facial muscles)

• Opisthothonus (arched trunk with hyperextended neck)

• Spasms, precipitated by minimal stimuli

Differential diagnosis: phenothiazine toxicity, strychnine poisoning, rabies.

Refer immediately to expert centre.

Intubate and ventilate if nec.

Prophylaxis

Immunisation of adults:

• two doses 6 wks apart

• third dose 6 mths later

Boosters every 10 yrs or 5 yrs if major wound.

In-wound management (see Table T2).

Conditions predisposing to thromboembolism:

• thrombophilia

• thrombocytosis

• polycythemia rubra vera

• disseminated intravascular coagulation

Thrombophilia

This refers to a disorder of haemostasis in the form of a primary coagulopathy leading to a tendency to thrombosis. It should be considered in patients with major venous thromboembolism ± FH of venous thrombosis.

The hereditary factors are: factor V Leiden gene mutation, prothrombin gene mutation, protein C deficiency, protein S deficiency and antithrombin deficiency.

Acquired factors are antiphospholipid Abs, ↑ homocysteine and lupus anticoagulant. These can all be measured in the laboratory. Consider screening patients with a DVT esp. in travellers at risk.

Warfarin

Warfarin actions

• Antagonises vitamin K

• Achieves full anticoagulation effect after 3–4 d

• Prothrombin time (INR ratio) of 2 times normal control indicates therapeutic effect

• Duration of effect is 2–3 d

• Antidote is vitamin K

Initiation of warfarin treatment

An estimate of the patient's final steady dose is made. The patient is commenced on this dose and the INR monitored daily and the dose altered accordingly.

• Measure INR first to establish baseline.

• Generally warfarin is commenced on same day or day after heparin is commenced.

• Heparin can be ceased when INR >2 for 2 consecutive d.

• Typical loading dose is 5–10 mg (o)/d for 2 d (avoid dose >30 mg over 3 d without INR).

• Adjust dosage according to Therapeutic Guidelines (see below) from 3rd d.

• Establish the INR in the therapeutic range, usually 2–3.

• Maintenance dose usually reached by d 5.

• The INR reflects the warfarin dose given 48 hrs earlier.

• An unacceptable INR is >5.0.

INR measurement schedule

Note:

• Warfarin should be continued for 3–6 mths and longer if major risk factors present.

• Watch for potential drug interactions.

New oral anticoagulants (NOACs)

The NOACs include the direct thrombin inhibitor dabigatran and the factor Xa inhibitors, apixaban and rivaroxaban. Used as an alternative to warfarin, they are currently indicated for thromboprophylaxis in non-valvular AF and in post-hip and knee replacement surgery. Rivaroxaban is also approved for treatment and secondary prevention of DVT and pulmonary embolism. They need less monitoring than warfarin, but there is no effective antidote at present. Contraindicated in renal failure.

In infants: nystatin oral drops or miconazole oral gel, 1 mL held in mouth as long as possible 4 times daily

In adults:

• amphotericin, 1 lozenge (10 mg) dissolved slowly in mouth, 6 hrly for 10 d or

• miconazole oral gel 50 mg 6 hrly dropped onto tongue and held in mouth as long as possible

Basically a habit under 4 yrs; can extend to 12 yrs. Only causes damage (‘buck teeth’) from time of onset of permanent teeth (6–7) but usually settles by then. Usually spontaneous cessation if not an issue between child and parent.

Management

• Can prevent by use of dummy (pacifier)

• No special diet or medication

• Avoid drawing attention to it

• Give child extra attention

• Help child explore other solutions/distractions

• Refer if prolonged and excessive

Thyroid disorders can be a diagnostic trap in family practice. Thyroid function tests are the basis of diagnosis. The serum TSH, the most sensitive index of thyroid function, is the key test. Various thyroid antibodies aid specific diagnosis. Relative values are summarised in Table T4.

Hypothyroidism (myxoedema)

DxT: tiredness + husky voice + cold intolerance

• Typically physical and mental slowing, lethargy, constipation, cold intolerance and characteristic signs (e.g. dry, cool skin)

• T₄—subnormal, TSH elevated (>10 is clear failure)

• TSH ↑; T₄ N → subclinical hypothyroidism ?treat

Thyroid medication

Thyroxine 100–150 mcg daily (once daily)

Note: Start with low doses (25–50 mcg/d) in elderly and ischaemic heart disease.

Monitor TSH levels monthly at first, then 2–3 mthly and when stable on optimum dose of T₄, every 2–3 yrs.

Hashimoto's thyroiditis

Commonly presents as postpartum hypothyroidism (thyroiditis):

• bilateral goitre, firm and rubbery

• may be hypothyroid or euthyroid (possible thyrotoxic early)

Diagnosis confirmed by a strongly +ve antithyroid antibody titre and/or fine needle aspiration cytology.

Neonatal hypothyroidism

This demands early diagnosis to avoid intellectual disability (cretinism): thyroxine replacement should be started by the 14th day.

Hyperthyroidism (thyrotoxicosis)

DxT: anxiety + weight loss + weakness

Classic symptoms of hyperactive metabolism, inc. heat intolerance, agitation, restlessness, warm and sweaty hands, may be absent in elderly patients. Avoid dismissing it as anxiety.

• T₃ (and T₄) elevated, TSH suppressed

• Possible antithyroid peroxidase antibodies

• Radioisotope scan a very useful test

Refer to endocrinologist for treatment.

Subacute thyroiditis

Usually transient and often follows a viral-type illness. May be pain over goitre and fever.

Some species of ticks are very dangerous so it is mandatory to remove the embedded tick, which should be totally removed, inc. the mouthparts. Be careful with children <5 yrs—usually in scalp and behind ear. Do not attempt to grab the tick by its body and tug.

First aid outdoor removal method

• Loop a strong thin thread, e.g. dental floss, around the head (as a half-hitch lasso) as close to the skin as possible then pull sharply with a twisting motion. A pyrethrin-based spray may help subdue the tick.

Office procedure

• Infiltrate a small amount of LA in the skin around the site of embedment.

• With a number 11 or 15 scalpel blade make the necessary very small excision, inc. the mouthparts of the tick, to ensure total removal.

• The small defect can usually be closed with a Band-Aid (or Steri-strips).

• Careful observation required after removal.

Motor and vocal tics are a feature of Tourette disorder.

If socially disturbing treat with haloperidol 0.25 mg (o) nocte, very gradually increasing to 2 g (max.) daily.

So-called tics of the eyelids are probably a focal dystonia (blepharospasm).

Tinea, or ringworm infections, are caused mainly by three major classes of dermatophytic organisms. It is most useful to perform skin scrapings and microscopy to look for encroaching septate hyphae. Confirm the diagnosis by fungal culture.

Tinea capitis

Clinical features

• Usually in children

• Patches of partial alopecia

• Scaly patches

• Small broken-off hair shafts

• Hairs usually fluoresce yellow–green with Wood's light (about 60%)

Treatment

(Topical is ineffective, commence with oral regimen)

• Terbinafine (o)

  • adults: 250 mg/d, 4 wks or until clinical resolution

  • children: 62.5–125 mg/d or

• Griseofulvin (o)

  • adults: 500 mg/d

  • children: 10 mg/kg/d (max. 500 mg) 4–8 wk course or

• Other options—fluconazole or ketoconazole

Also: Take hair plucking and scale for culture; Selsun or ketoconazole shampoo twice wkly.

Tinea cruris (jock itch)

• Related to chafing in groin (e.g. tight pants, and esp. nylon ‘jock straps’)

• Scaling, esp. at margin

• Well-defined border

Diagnostic aids

• Skin scrapings should be taken from the scaly area for preparation for microscopy.

• Wood's light may help the diagnosis, particularly if erythrasma is suspected.

Treatment

• Soak the area in a warm bath and dry thoroughly.

• Apply terbinafine 1% cream or gel/d for 7 d or an imidazole topical preparation (e.g. clotrimazole 1% or miconazole 2% cream); rub in a thin layer bd for 14 d after symptoms resolve.

• When almost healed, apply tolnaftate dusting powder bd for 3–4 wks.

• If itch severe: add 1% hydrocortisone cream.

• If weeping: apply Burow's solution compresses.

• For persistent or recurrent eruption, use oral terbinafine for 2–4 wks or oral griseofulvin for 4 wks, or itraconazole for 7 d.

Tinea pedis (athlete's foot)

Symptoms

Commonest symptoms are itchiness and foot odour. There is scaling, maceration and fissuring of the skin between the fourth and fifth toes and also third and fourth toes.

Management

• Patient education.

• Keep feet clean and dry.

• Use antifungal powder between toes after drying.

• Wear socks of natural absorbent fibres—cotton and wool (avoid synthetics).

• Wear open sandals and shoes with porous soles and uppers (if possible).

• Use thongs in public showers.

• Keep toe spaces separated if interdigital.

Treatment

As for tinea cruris with preference for terbinafine 1% cream daily for 1 wk (apply after drying) and review. One of the imidazole preparations also appropriate. If widespread or smelly vesiculobullous (take scrapings), use griseofulvin (fine particle) 500 mg (o) daily for 6 wks or terbinafine 250 mg (o) for 2–6 wks.

Tinea of toenails and fingernails (tinea unguium)

• Usually associated with tinea pedis.

• Nails show white spots; may be yellow and crumbling.

• Starts at the edge of periphery and spreads towards base.

• Diagnosis is by culture and histology of distal nail plate clippings placed in formalin.

Treatment

Topical:

• Cut affected nail well back, elevate the nail slightly at the edges and apply:

  • tincture miconazole (Daktarin) to and under nail bd for 8–12 wks or

  • terbinafine cream bd for 8–12 wks or

  • amorolfine 5% nail lacquer (Loceryl) 1–2 times wkly after filing until resolved (fingers 6 mths, toes 9 mths)

  Consider twice daily application of tea tree oil indefinitely for tinea pedis.

General (usually requires oral treatment):

• Terbinafine 250 mg (o)/d

  • fingernails 6 wks

  • toenails 12 wks

  This is the treatment of choice for tinea unguium or

• Itraconazole (Sporanox) 200 mg (o) bd—as pulse therapy: 1 wk on, 3 wks off × 2 fingernails, × 3 toenails

Tinea corporis

Management

• Ensure not handling guinea pigs (facial lesions).

• Take skin scrapings.

Treatment: clotrimazole 1% or miconazole 2% applied bd for 2–4 wks or terbinafine 1% cream or gel once daily for 1 wk. Oral terbinafine or griseofalvin for up to 6 wks if no response or widespread.

Tinea incognito

This is the term used for unrecognised tinea infection due to modification with corticosteroid treatment. The lesions are enlarging and persistent, esp. on the groins, hands and face.

The sequence of events is initial symptomatic relief of itching, stopping the ointment or cream and then relapse.

Precautions

• Exclude wax, drugs inc. marijuana, NSAIDs inc. aspirin, antidepressants, vascular disease, venous hum (jugular vein), Ménière syndrome, depression, aneurysm, acoustic neuroma and vascular tumours.

• Beware of lonely elderly people living alone (suicide risk).

Note: Otosclerosis in young adults causes tinnitus and deafness.

Investigations

• Audiological examination by audiologist

• Tympanometry and speech discrimination

• MRI (if serious cause suspected)

Management

• Treat any underlying cause and aggravating factors

• Educate and reassure the patient/counselling

Holistic approach to minimise symptoms (options)

• Relaxation techniques

• Cognitive behaviour therapy

• Background ‘noise’ (e.g. music playing during night) or

• Tinnitus maskers or

• Hearing aids (based on audiological assessment)

• Consider hypnotherapy

• Refer to: www.tinnitus.asn.au

Drug trials to consider (limited efficacy)

• Clonazepam 0.5 mg nocte

• Minerals (e.g. zinc and magnesium)

Acute severe tinnitus ​

Slow IV injection of 1% lignocaine. Up to about 5 mL can be very effective.

Those for investigation

• Asymmetrical with hearing loss (?acoustic neuroma)

• True pulsatile tinnitus

• Severe hearing loss

Tiredness can be a symptom of a great variety of serious and uncommon diseases, inc. malignant disease. The most probable diagnoses to consider are:

• tension, stress and anxiety

• depression

• viral or postviral infection

• sleep-related disorders, e.g. sleep apnoea

It is important not to overlook drugs whether self-administered or iatrogenic as a cause. Other masquerades are endocrine disorders and anaemia.

Key screening investigations are FBE, ESR/CRP, blood sugar, serum electrolytes, LFTs, iron studies, TFTs, CXR.

Sleep-related disorders

An important cause of daytime tiredness is a sleep disorder such as obstructive sleep apnoea, which results in periodic hypoventilation during sleep. It occurs in 2% of the general population in all age groups and in about 10% of middle-aged men. A history of snoring is a pointer to the problem.

Referral to a comprehensive sleep disorder centre is appropriate if this disorder is suspected.

Narcolepsy

Narcolepsy is a condition where periods of irresistible sleep occur in inappropriate circumstances and consists of a tetrad of symptoms:

• sudden brief sleep attacks (15–20 mins)

• cataplexy—a sudden loss of muscle tone in the lower limbs—may slump to floor

• sleep paralysis

• hypnagogic (terrifying) hallucinations on falling asleep

Treatment

• Methylphenidate (Ritalin) or amphetamines (dexamphetamine)

• Tricyclic antidepressants (small doses) for cataplexy

Chronic fatigue syndrome (CFS)

CFS is defined as debilitating fatigue, persisting or relapsing over 6 mths, associated with a significant reduction in activity levels of at least 50% and for which no other cause can be found. Prevalence ∼1%; ♀ : ♂ ∼3:2.

It does appear to be a real illness, probably caused by a virus. Standard screen—FBE, ESR, electrolytes, urea and creatinine, calcium, LFTs, FSH, urinalysis.

Management

• Recognition of CFS

• Ongoing support

• Rest and pacing activity; avoid aggr. factors, e.g. alcohol

• A supervised self-management action plan/multidisciplinary intervention

• Cognitive therapy (best evidence) meditation and group support

Best evidence indicates CBT from a skilled therapist and exercise are beneficial.

Medication options:

• Antidepressant trial (if signs of depression) but weak evidence

• NSAIDs for florid aches and pains

The causes of a sore or painful tongue are similar to those of a sore mouth or throat. The cause is usually obvious upon examination but there are some obscure causes. Investigations may include an FBE, serum vitamin B₁₂, folate and ferritin, a swab or a biopsy of a suspicious lesion.

Tongue tips

• Look for evidence of trauma, esp. from a sharp tooth.

• A miserable child with a painful mouth and tongue is likely to have acute primary herpetic gingivostomatitis.

• In your history take note of self-medications, esp. sucking aspirin, a history of skin lesions (e.g. lichen planus) and consider underlying diabetes or immunosuppression.

• A long history of soreness with spicy or other foods indicates benign migratory glossitis (geographical tongue) or median rhomboid glossitis.

• Any non-healing or chronic ulcer requires urgent referral.

• Glossodynia (painful tongue) characteristically presents as burning pain on the tip of the tongue. It can be a real ‘heartsink’ presentation. Consider depressive illness as an underlying cause.

• Macroglossia (large tongue): consider acromegaly, myxoedema, amyloidosis, lymphangioma.

• Strawberry tongue: consider scarlet fever, Kawasaki's disease.

Erythema migrans

Geographical tongue

Black or hairy tongue

This causes bad tastes and a malodorous oral cavity. Basically a harmless condition that can be related to smoking, poor oral hygiene or use of antibiotics.

Treatment

• Brush with toothbrush using sodium bicarbonate paste or

• Suck fresh pineapple pieces: cut a thin slice into eight segments—slowly suck a segment on the back of the tongue for 40 secs, then slowly chew it

Muscle energy therapy, which is simple to use and highly effective, is recommended.

• The main diseases facing the international traveller are traveller's diarrhoea (relatively mild) and malaria, esp. CRFM.

• Infections transmitted by mosquitoes include malaria, yellow fever, Rift Valley fever, Japanese encephalitis and dengue fever. Preventing their bites is excellent prevention.

• STIs, inc. HIV, of concern in certain areas.

  Prevention of disease is a key role for the GP (Table T6)

Malaria

Prevention

Follow two simple rules:

• Avoid mosquito bites.

• Take antimalarial medicines regularly.

Consider:

• Smearing an insect repellent on exposed parts of the body

• Using mosquito nets

• Impregnating nets with permethrin (Ambush) or deltamethrin

Drug prophylaxis

Treatment of breakthrough malaria during travel (where medical care unavailable):

• Mefloquine 500 mg (2 tabs) statim; repeat after 6–8 h or artemether/lumefantrine (Riamet) 4 tabs at 0, 8, 24, 36, 48, 60 h

Fever in the returned traveller

Probability diagnosis: malaria, respiratory tract infection inc. bacterial pneumonia, gastroenteritis, dengue fever, Hepatitis A.

Serious disorders: as above, TB, typhoid, encephalitis, meningococcal meningitis, meloidosis, amoebiasis (liver abscess), all haemorrhagic fevers, schistosomiasis, African trypanosomiasis.

Investigations (if no obvious cause): FBE (?eosinophils), ESR/CRP, thick and thin blood films, blood culture, LFTs, urine-M & C, stool-M & C, new malaria tests, CXR.

Diarrhoeal illnesses

Traveller's diarrhoea

The illness is usually mild and lasts only 2–3 d. Unusual to last longer than 5 d. Mainly caused by an E. coli strain.

Treatment

• Maintain fluid intake—cordial or diluted soft drink

• Antimotility agents (judicious use: if no blood in stools) loperamide (Imodium) 2 caps statim then 1 after each unformed stool (max. 8 caps/d)

• Attend to hydration

• Patient can self-administer antibiotic—e.g. single-dose norfloxacin 800 mg (o) statim; or azithromycin (Nepal, India, Thailand)

• Imodium in adults

• Admit to hospital

• Attend to hydration—use an oral hydrate solution (e.g. Gastrolyte or WHO formulation)

• Imodium in adults

• Antibiotic: norfloxacin or azithromycin

• Consider giardiasis and amoebiasis.

• Take 3 faecal specimens for analysis.

Also consider Campylobacter jejuni, Salmonella, Yersinia, Cryptosporidium, strongloides, schistosomiasis.

Preventive advice (countries at risk)

• Purify all potentially contaminated water by boiling for 10 mins. 2% tincture of iodine is useful.

• Do not use ice or salads.

• Drink hot drinks or reputable bottled soft drinks.

Typhoid fever

Incubation period 10–14 d.

Features: ‘step ladder’ fever, abdominal pain, headache (classic), ‘pea soup’ diarrhoea, relative bradycardia

DxT: ‘stepladder’ fever + abdominal pain + bradycardia → typhoid (early)

Diagnosis: on suspicion → blood culture

Treatment: ciprofloxacin 500 mg (o) bd for 7–10 d or azithromycin

Cholera

Incubation period few hours–5 days. Usually mild, uncomplicated episode diarrhoea. Fulminant lethal form with severe water and electrolyte depletion, intense thirst, oliguria.

DxT: fever + vomiting + abrupt onset ‘rice water’ diarrhoea → cholera

Diagnosis: stool M & C (Vibrio cholera)

Treatment: hospitalisation for IV fluids and electrolytes, azithromycin or ciprofloxacin

Amoebiasis

Consider it in sick traveller from endemic area with severe diarrhoea with blood and mucus.

Diagnosis: stool microscopy, faecal antigen

Treatment: metronidazole 600 mg (o) tds for 7–10 d

Giardiasis

Often asymptomatic; symptoms include abdominal cramps, bloating, flatulence and bubbly, foul smelling diarrhoea.

Diagnosis: 3 specimens faeces-microscopy; ELISA/PCR

Treatment: metronidazole or tinidazole, scrupulous hygiene

Specific acquired tropical infections

Dengue (‘breakbone’) fever and chikungunya

Similar viral mosquito-borne infections.

Febrile illness with severe aching of muscles (myalgia +++) and joints. Possible characteristic erythematous rash with ‘islands of sparing’.

DxT: fever + severe myalgia/arthritis + rash → dengue

Diagnosis: clinical suspicion → specific antibodies

Treatment: is symptomatic with supportive follow-up. Push fluids & simple analgesics. Depression a worry.

Melioidosis

Caused by a Gram-negative bacillus. It may manifest as a focal infection or as septicaemia with abscesses in the lung, kidney, liver or spleen. It presents with fever, cough and myalgia.

DxT: fever + pneumonia + myalgia → melioidosis

Diagnosis: blood culture, swabs from focal lesions, haemagglutination test

Treatment: ceftazidime 2 g IV 6–8 hrly or meropenem or imipenem (all 14 d) then oral cotrimoxazole ± doxycycline bd + folic acid for 3 mths

Malaria

• Incubation period: P. falciparum 7–14 d; others 12–40 d

• Most present within 2 mths of return from tropics

• Can present up to 2 or more yrs

Symptoms

• High fever, chills, rigor, sweating, headache

• Usually abrupt onset

• Can have atypical presentations (e.g. diarrhoea, abdominal pain, cough)

Other features

• Beware of modified infection.

• Must treat within 4 d.

• Typical relapsing pattern often absent.

• Thick smear allows detection of parasites.

• Thin smear helps diagnose malaria type.

If index of suspicion high, repeat the smear (‘no evidence of malaria’ = 3 negative daily thick films). Monocytosis is a helpful diagnostic clue. Cerebral malaria and blackwater fever are severe and dramatic. Special new tests (e.g. PCR, ICT cards) now available.

Treatment

• Admit to hospital with infectious disease expertise

• Supportive measures inc. IV fluids

• P. vivax, P. ovale, P. malariae (depending on country of source):

  • artemether/lumefantrine (Riamet) or

  • chloroquine + primaquine: 14 d (check G-6-PD first)

• P. falciparum:

  • artemether/lumefantrine or

  • uncomplicated: quinine (o) + doxycycline or clindamycin or

  • atovaquone/proguanil (Malarone)

• Severe and complicated: quinine IV then quinine (o) or artesunate IV then Riamet (o)

Note: Check for hypoglycaemia. Beware if antimalarial use in previous 48 h.

Prevention: See Travel medicine and tropical infections

Japanese B encephalitis and meningococcal meningitis

Consider these serious infections in a patient presenting with headache, fever and malaise before neurological symptoms such as delirium, convulsions and coma develop. Admit to hospital ASAP for supportive treatment.

Schistosomiasis (bilharzia)

• First sign is local skin reaction (‘swimmer's itch’)

• Generalised allergic reaction (fever, malaise, urticaria) some days later

• Other symptoms (e.g. nausea, vomiting, cough)

Diagnosis: specific serology; also eggs in excreta

Treatment: praziquantel

Prevention: travellers should be warned against drinking from or swimming and wading in dams, watercourses or irrigation channels esp. in Egypt and Africa

African trypanosomiasis (sleeping sickness)

• Fever, headache and a skin chancre or nodule

Two stages possible:

• Haemolymphatic stage: lymphadenopathy, hepatosplenomegaly

• Meningoencephalitic stage: including hypersomnolence

Diagnosis: on blood smear or chancre aspirate (trypomastigotes)

Treatment: suramin IV

Prevention: avoid bites of the tsetse fly

Plague (‘black death’)

Caused by Yersinia pestis—transmitted by fleas

Basically 3 forms:

1. bubonic plague—painful suppurating lymph nodes (buboes)

2. pneumonic plague—flu-like symptoms, sepsis, haemorrhage

3. septicaemic plague

Diagnosis: serology and smear/culture buboes; repid dipstick tests

Treatment: streptomycin and doxycycline

Rabies (a rhabdovirus infection)

At first: malaise, headache, painful or itchy bite, fever, agitation. Then either paralytic ‘dumb rabies’ or encephalitic ‘furious rabies’ including hydrophobia (fear of drinking water because of painful pharyngeal muscle spasm)

DxT: painful/itchy bite + agitation + hydrophobia → rabies

Diagnosis: viral testing PCT (saliva or CSF)

Treatment: rabies immunoglobin (within 48 h); rabies vaccine (if unimmunised)

Hansen's disease (leprosy)

Diagnosis is one or more of (WHO):

• skin lesions—anaesthetic, hypopigmented or reddish maculopapules or annular lesions

• thickened peripheral nerves → neuropathy

• demonstration of acid-fast bacilli in skin smear or on biopsy

It can be localised (tuberculoid) or generalised (lepromatous).

Diagnosis: biopsy, lepromin test, PCR, skin smear

Treatment: multiple drugs (see www.who.int/lep)

Leishmaniasis

• Cutaneous leishmaniasis—erythematous papules

• Visceral leishmaniasis (Kala azar):

  • fever, wasting, hepatosplenomegaly, lymphadenopathy

  • hyperpigmentation of skin (black fever)

Diagnosis: serology and tissue biopsy

Treatment: complex—seek advice

Cutaneous myiasis

Consider infestation of body tissues by larvae (maggots) of flies if traveller presents with ‘itchy boils’ (e.g. tumbu fly, botfly, New World screw worm).

Treatment: Vaseline over lump, pressure and tweezer extraction of maggot

Helminth (worm) infections

These are classified as nematodes (roundworms), cestodes (tapeworms) and trematodes (flukes). The roundworms which include pinworm (Enterobius vermicularis), whipworm (Trichuris trichiura), human roundworm (Ascaris lumbricoides), human threadworm (Strongyloides stercoralis), hookworm (Ankylostomiasis), filiariasis and larva migrans are the most prevalent worldwide.

Pinworms (also called threadworms)

• Enterobius vermicularis is the most ubiquitous parasitic worm

• Causes pruritus ani

• Inspect anus in child about 1 h after sleeping

• Collect eggs with adhesive tape on perianal skin

Treatment

• Scrupulous hygiene; shower each morning; cut fingernails short

• Wash nightwear, underwear and bedlinen in very hot water daily for several days

• Veterinarian check of household pets

• Use any one of pyrantel, albendazole, praziquantel or mebendazole as single dose (e.g. pyrantel (o) 10 mg/kg up to 1000 mg). Repeat in 2–3 wks: patient and household contacts.

Human roundworm

• Basically light infections that rarely cause problems, usually observed in stool

• Diagnosis: finding eggs in the faeces

• Treat with pyrantel or albendazole as single dose

Whipworm

About 1–2 cm long these worms can cause failure to thrive, anaemia, abdominal pain, diarrhoea and rectal prolapse with heavy infestation.

Diagnosis: microscopy of stool

Treatment: single large dose of mebendazole or aldendazole or 3 d course

Human threadworm (strongyloides)

These tiny parasites (2 mm or so) are common worldwide. Features if symptomatic are recurrent (low grade) abdominal pain, diarrhoea, ± urticaria and respiratory symptoms. Blood eosinophilia. Can live and reproduce in the body for many years. Aggravated by steroid therapy e.g. septicaemia.

DxT: mild abdominal pain + recurrent diarrhoea + blood eosinophilia → strongyloides

Diagnosis: larvae in faeces, duodenal biopsy, ELISA test

Treatment: ivermectin 200 mcg/kg (o) two doses 2 wks apart (not in children) or albendazole 200 mg bd, 3 d. Antihistamines for pruritus

Cutaneous larva migrans (creeping eruption)

A pruritic, erythematous serpiginous eruption on the skin esp. hands, legs and feet. The larvae (of dog or cat hookworms) keep just ahead of the lesion.

Diagnosis: clinical appearance; eosinophilia

Treatment: usually self-limiting. Can use single dose ivermectin or albendazole

Filariasis

1. Lymphatic filariasis—chronic lymphoedema may manifest as a hydrocele, elephantiasis of extremities, genitals, e.g. scrotum, and breasts

   Diagnosis: blood film and serology

2. Onchoerciasis (river blindness)—skin disease and chronic eye disease (uveitis and optic atrophy)

   Diagnosis: PCR

   Treatment of filariasis: ivermectin

3. Loiasis (due to Loa Loa—a filaria)

   In Africa: painful swellings of angioedema (Calabars) mainly on limbs, eosinophilia, worms may migrate across eyes (subconjunctivae)

   Diagnosis: microscopy of mid-day blood sample

   Treatment: diethylcarbamazine 6 mg/kg (o) stat.

Hydatid disease

Parasites from sheep areas can migrate anywhere but usually form cysts on lungs. May be asymptomatic or skin cysts and abdominal discomfort.

Diagnosis: serology, ultrasound

Treatment: surgical cystectomy, albendazole

Dracunculus medimensis (Guinea worm)

Causes local symptoms such as pain and intense itching at skin ulcer or blister as the worm emerges into the skin. The longest nematode.

Treatment: slow extraction of pre-emerging worms, metronidazole ± corticosteroids

Hookworm

• First sign—‘creeping eruption’ at entry point on feet

• 1–2 wks later—respiratory symptoms like pneumonia

• Anaemia follows

• Iron deficiency (commonest cause in world)

Diagnosis: larvae or ova in stool

Treatment: single dose mebendazole or pryantel

Prevention: use footwear in endemic areas

Viral haemorrhagic fevers (VHF)

These infections, which belong to the domain of tropical medicine, include Ebola virus, Lassa fever, yellow fever, dengue, chikungunya and hantavirus. Many have names based on the area where the VHF was first described, esp. South American types, e.g. Junin, Machupo, Sabia.

Ebola virus

Early symptoms: fever, myalgia, headache, abdominal symptoms (ANV, diarrhoea, pain), upper respiratory (cough, sore throat, chest pain), flushed skin or rash. May progress to thrombocytopenia, anaemia, DIC with bleeding including frank haemorrhage, hypotension/shock and multiorgan failure.

Transmission: direct body contact (body fluids from affected person or dead person); contaminated objects (needles, medical equipment) and infected animals.

Diagnosis: PCR, histopathology

Treatment: supportive care, strict isolation and quarantine measures; the future—antivirals, synthetic antibodies

Yellow fever

Milder cases present with flu-like symptoms, relative bradycardia (Faget's sign) and albuminuria. Severe cases develop abrupt fever with prostration, jaundice and abnormal bleeding.

Diagnosis: viral culture, serology (ELISA)

Oral preparations:

• dimenhydrinate (Dramamine, Travacalm) or

• promethazine theoclate (Avomine) or promethazine HCI (Phenergan) or

• hyoscine (Kwells)

Take 30–60 mins before the trip.

Repeat 4–6 hrly during trip (max. 4 doses in 24 h).

Dermal:

• hyoscine dermal disc (Scop); apply to dry hairless skin behind ear 5–6 h before travel, leave on for 3 d.

Tremor is an important symptom to evaluate correctly. A common mistake is to misdiagnose the tremor of essential tremor for that of Parkinson disease.

Tremor: diagnostic strategy model

Probability diagnosis

• Benign essential (familial) tremor

• Senility

• Physiological

• Parkinson disease (incl. drug-induced PD)

• Anxiety/emotional

• Alcohol

Serious disorders not to be missed

• Vascular:

  • cerebral infarction → Parkinsonism

• Infection:

  • meningoencephalitis

  • tertiary syphilis

• Cancer/tumour:

  • cerebral tumour (frontal lobe)

Other:

• toxicity from organ failure (kidney, liver, lungs)

Pitfalls (often missed)

• Cerebellar disease

• Multiple sclerosis

• Alzheimer dementia

• Uraemia of kidney failure

• CO₂ retention of respiratory failure

• Hepatic failure

Rarities:

• hepatolenticular degeneration (Wilson disease)

• lesion of midbrain (red nucleus)

Masquerades checklist

• Drugs esp. withdrawal, e.g. opioids

• Thyroid/other endocrine esp. hyperthyroidism

Is the patient trying to tell me something?

Anxiety (esp. hyperventilation)

Classification

Resting tremor—Parkinsonian

The tremor of Parkinson disease is present at rest. The hand tremor is most marked with the arms supported on the lap and during walking. The characteristic movement is ‘pill-rolling’. See Parkinson disease.

Action or postural tremor

This fine tremor is noted by examining the patient with the arms outstretched and the fingers apart. Causes include:

• essential tremor (also called familial tremor or benign essential tremor)

• senile tremor

• physiological

• anxiety/emotional

• hyperthyroidism

• alcohol

• drugs (e.g. drug withdrawal—heroin, cocaine, alcohol, dexedrine, lithium)

Intention tremor (cerebellar disease)

This coarse oscillating tremor is absent at rest but exacerbated by action and increases as the target is approached. It is tested by ‘finger-nose-finger’ touching.

Flapping (metabolic tremor)

A flapping or ‘wing-beating’ tremor is observed when the arms are extended with hyperextension of the wrists. Typically caused by metabolic disorders such as uraemia, hepatic failure, Wilson syndrome and respiratory failure.

Essential tremor

Called benign, familial, senile or juvenile tremor.

Triad of features

• +ve family history

• Tremor with little disability, inc. head movement (titubation)

• Normal gait

Management

• Explanation and reassurance

• Drugs usually not needed

• Discreet use of alcohol beneficial

If necessary: propranolol (first choice) 10–40 mg (o) bd or primidone

See Otitis externa

For severe painful otitis externa in tropics:

• prednisolone (orally) 15 mg statim, then 10 mg 8 hrly for 6 doses followed by

• Merocel ear wick

• topical Kenacomb or Sofradex drops for 10 d