SKIN DISEASEsSKIN DISEASEsand flooding crisisand flooding crisis

TANONGKIET TIENTHAVORN, MDTANONGKIET TIENTHAVORN, MD

, the articles review, the articles review

FloodingFlooding

Floods are the most common natural disasters that affect developed and Floods are the most common natural disasters that affect developed and developing countries developing countries

people living in developing countries are more vulnerable to floods, and flood people living in developing countries are more vulnerable to floods, and flood size and populations at risk are variable.size and populations at risk are variable.

They cause many problems such as shortage of food and clean water, various They cause many problems such as shortage of food and clean water, various health problems and general well beinghealth problems and general well being

According to the OFDA/CRED International Disaster Database , the tsunami According to the OFDA/CRED International Disaster Database , the tsunami of December 26 was undoubtedly the most lethal natural disaster that of December 26 was undoubtedly the most lethal natural disaster that occurred in 2004occurred in 2004

In 2004, deaths were reported from flash, river, and urban/small-stream In 2004, deaths were reported from flash, river, and urban/small-stream floods. The 0- to 9- and 20- to 29-year-old age groups had the most deaths at floods. The 0- to 9- and 20- to 29-year-old age groups had the most deaths at 14 each, of which 62% were men. In recent years, 50% or more of all flood-14 each, of which 62% were men. In recent years, 50% or more of all flood-related deaths have occurred in automobiles.related deaths have occurred in automobiles.

Surg Clin N Am 86 (2006) 557–578Surg Clin N Am 86 (2006) 557–578

Surg Clin N Am 86 (2006) 557–578Surg Clin N Am 86 (2006) 557–578

Surg Clin N Am 86 (2006) 557–578Surg Clin N Am 86 (2006) 557–578

Cause of floodingCause of flooding

1. Topical cyclone : depression, typhoon1. Topical cyclone : depression, typhoon

2. Intertropical convergence zone (2. Intertropical convergence zone (ร่�องมร่สุ�มร่�องมร่สุ�ม))

3. Strong monsoon3. Strong monsoon

4. Prolonged rain storm (4. Prolonged rain storm (พายุ�ฟ้�าคะนองพายุ�ฟ้�าคะนอง))

5. Hide tide (5. Hide tide (น��าทะเลหน�นสุ�งน��าทะเลหน�นสุ�ง): 2o % higher than ): 2o % higher than regular sea level with sun, moon and earth in regular sea level with sun, moon and earth in lineline

6. earthquake, volcano6. earthquake, volcano

types of natural floodtypes of natural flood

1. flash flood (1. flash flood (น��าป่�าไหลหลากน��าป่�าไหลหลาก))

2. drainage flood (2. drainage flood (น�า�ท�วมขั�งน�า�ท�วมขั�ง))

3. River flood (3. River flood (น��าล�นตล !งน��าล�นตล !ง))

4. Storm surges (4. Storm surges (คล"!นพายุ�ซั�ดฝั่&! งคล"!นพายุ�ซั�ดฝั่&! ง))

5. Tsunami 5. Tsunami

สุถานการ่ณ์)น*าท�วมในป่ร่ะเทศไทยุ พ สุถานการ่ณ์)น*าท�วมในป่ร่ะเทศไทยุ พ..ศศ. 2548 - 2552. 2548 - 2552

ป่ร่ะเทศไทยุอยุ��เขัตอ ทธิ พลขัองมร่สุ�ม ป่ร่ะเทศไทยุอยุ��เขัตอ ทธิ พลขัองมร่สุ�ม 2 2 ฤด� ป่ร่ะมาณ์ฤด�กาลละ ฤด� ป่ร่ะมาณ์ฤด�กาลละ 6 6 เด"อนเด"อน

1. 1. มร่สุ�มตะว�นตกเฉี0ยุงใต� มร่สุ�มตะว�นตกเฉี0ยุงใต� (Southwest monsoon) (Southwest monsoon) ก�อให�เก ดอ�ทกภั�ยุก�อให�เก ดอ�ทกภั�ยุ ได� เน"!องจากเม"!อพ�ดจาก มหาสุม�ทร่อ นเด0ยุป่ะทะขัอบฝั่&! งตะว�นตกขัอง ได� เน"!องจากเม"!อพ�ดจาก มหาสุม�ทร่อ นเด0ยุป่ะทะขัอบฝั่&! งตะว�นตกขัอง

ภัาคใต� และเม"!อผ่�านอ�าวไทยุแล�วจะป่ะทะขัอบฝั่&! งตะว�นออกขัอง ภัาคใต� และเม"!อผ่�านอ�าวไทยุแล�วจะป่ะทะขัอบฝั่&! งตะว�นออกขัองพฤษภัาคมพฤษภัาคม--ตล�าคมตล�าคม

2. 2. มร่สุ�มตะว�นออกเฉี0ยุงเหน"อ มร่สุ�มตะว�นออกเฉี0ยุงเหน"อ (Northeast monsoon) (Northeast monsoon) เร่ !มต��งแต�เร่ !มต��งแต� ป่ลายุเด"อนต�ลาคมถ7งสุ �นเด"อน ก�มภัาพ�นธิ) ต��งต�นพ�ดจากป่ร่ะเทศจ0น ป่ลายุเด"อนต�ลาคมถ7งสุ �นเด"อน ก�มภัาพ�นธิ) ต��งต�นพ�ดจากป่ร่ะเทศจ0น

และไซับ0เร่0ยุผ่�านทะเลจ0นใต�ป่ะทะขัอบฝั่&! งเว0ยุดนาม สุ�วนท�0หล�ดจากป่ลายุ และไซับ0เร่0ยุผ่�านทะเลจ0นใต�ป่ะทะขัอบฝั่&! งเว0ยุดนาม สุ�วนท�0หล�ดจากป่ลายุแหลมอ นโดจ0นจะพ�ดผ่�านอ�าวไทยุตอนใต�ป่ะทะขัอบฝั่&! งตะว�นออกขัองแหลมอ นโดจ0นจะพ�ดผ่�านอ�าวไทยุตอนใต�ป่ะทะขัอบฝั่&! งตะว�นออกขัอง

ภัาคใต� หร่"อฝั่�� งตะว�นตกขัองอ�าวไทยุ ภัาคใต� หร่"อฝั่�� งตะว�นตกขัองอ�าวไทยุ

ขั�อม�ลยุ�อนหล�งขั�อม�ลยุ�อนหล�ง4848ป่9ป่9((พพ..ศศ.2493-2540).2493-2540)สุร่�ป่สุร่�ป่ฤด�กาลเก ดอ�ทกภั�ยุตามภัาคต�างๆด�งน0�ฤด�กาลเก ดอ�ทกภั�ยุตามภัาคต�างๆด�งน0�

FLOODING AND COMMUNICABLE DISEASES FACT SHEETFLOODING AND COMMUNICABLE DISEASES FACT SHEET

Risk assessmentRisk assessment

Floods can increase the transmission of the Floods can increase the transmission of the following commnicable diseasesfollowing commnicable diseases

1.Water-borne diseases, such as typhoid 1.Water-borne diseases, such as typhoid fever, cholera, leptospirosis and hepatitis A fever, cholera, leptospirosis and hepatitis A

2.Vector-borne diseases, such as malaria, 2.Vector-borne diseases, such as malaria, dengue and dengue haemorrhagic fever, dengue and dengue haemorrhagic fever, yellow fever,and West Nile Fever1.yellow fever,and West Nile Fever1.

3.Risk posed by corpse3.Risk posed by corpse

Water-borne diseasesWater-borne diseases

major risk factor for outbreaks : contamination of major risk factor for outbreaks : contamination of drinking-water facilitiesdrinking-water facilities

In Tajikistan in 1992, the flooding of sewage In Tajikistan in 1992, the flooding of sewage treatment plants led to the contamination of river treatment plants led to the contamination of river water: no significant increase in incidence of water: no significant increase in incidence of diarrhoeal diseases was reported.diarrhoeal diseases was reported.

A typhoon in Truk District, Trust Territories of the A typhoon in Truk District, Trust Territories of the Pacific in 1971 disrupted catchment water sources Pacific in 1971 disrupted catchment water sources and forced people to use many different sources of and forced people to use many different sources of groundwater that were heavily contaminated with groundwater that were heavily contaminated with pig faeces. As a result, there was an outbreak of pig faeces. As a result, there was an outbreak of muntidiasis, an intestinal protozoan. A cyclone and muntidiasis, an intestinal protozoan. A cyclone and flooding in Mauritius in 1980 led to an outbreak of flooding in Mauritius in 1980 led to an outbreak of typhoid fever.typhoid fever.

direct contact with polluted water : wound direct contact with polluted water : wound infection, dermatitis, conjunctivitis and ENT infection, dermatitis, conjunctivitis and ENT infectioninfection

epidermic prone: only leptospirosis spreaded epidermic prone: only leptospirosis spreaded by proliferation of rodents which shed large by proliferation of rodents which shed large amounts of leptospires in the urineamounts of leptospires in the urine

out break of leptospirosis occured in out break of leptospirosis occured in Brazil Brazil (1983, 1988 and 1996), in Nicaragua (1995), (1983, 1988 and 1996), in Nicaragua (1995), Krasnodar region, Russian Federation (1997), Krasnodar region, Russian Federation (1997), Santa Fe, USA (1998) Orissa, India (1999) and Santa Fe, USA (1998) Orissa, India (1999) and Thailand (2000)Thailand (2000)

Vector borne diseaseVector borne disease

expansion in the number and range of vector habitatsexpansion in the number and range of vector habitats

Standing water caused by heavy rainfall or overflow of rivers can act as breeding Standing water caused by heavy rainfall or overflow of rivers can act as breeding sites for mosquitoessites for mosquitoes

enhance the potential for exposure of the disaster-affected population and enhance the potential for exposure of the disaster-affected population and emergency workers to infections such as dengue, malaria and West Nile fever. emergency workers to infections such as dengue, malaria and West Nile fever.

Flooding may initially flush out mosquito breeding, but it comes back when the Flooding may initially flush out mosquito breeding, but it comes back when the waters recedewaters recede

lag time is usually around 6-8 weeks before the onset of a malaria epidemic.lag time is usually around 6-8 weeks before the onset of a malaria epidemic.

The risk of outbreaks is greatly increased by complicating factors: human The risk of outbreaks is greatly increased by complicating factors: human behaviour (increased exposure to mosquitoes while sleeping outside, a behaviour (increased exposure to mosquitoes while sleeping outside, a temporary pause in disease control activities, overcrowding), habitat which temporary pause in disease control activities, overcrowding), habitat which promote mosquito breeding (landslide, deforestation, river damming, and promote mosquito breeding (landslide, deforestation, river damming, and rerouting).rerouting).

MalariaMalaria epidemics in the wake of flooding are a well- epidemics in the wake of flooding are a well-known phenomenon in malaria-endemic areas world-wide. For known phenomenon in malaria-endemic areas world-wide. For instance, an earthquake and subsequent flooding instance, an earthquake and subsequent flooding in Costa in Costa RicaRica’’s s Atlantic region in 1991 and flooding on the Dominican Atlantic region in 1991 and flooding on the Dominican Republic in 2004 led to malaria outbreaks.Republic in 2004 led to malaria outbreaks.

Periodic flooding linked to Periodic flooding linked to El Nino-Southern Oscillation (ENSOEl Nino-Southern Oscillation (ENSO) ) is associated with malaria epidemics in the dry coastal region is associated with malaria epidemics in the dry coastal region of northern of northern PeruPeru and with the resurgence of dengue in the past and with the resurgence of dengue in the past 10 years throughout the American continent.10 years throughout the American continent.

West Nile Fever West Nile Fever has resurged in Europe subsequent to heavy has resurged in Europe subsequent to heavy rains and flooding, with outbreaks rains and flooding, with outbreaks in Romania in Romania in 1996-97, in the in 1996-97, in the Czech Republic in 1997 and Italy in 1998.Czech Republic in 1997 and Italy in 1998.

risk posed by corpsesrisk posed by corpses

Most agents do not survive long in the human body after Most agents do not survive long in the human body after deathdeath (exception of HIV - which can be up to 6 days) (exception of HIV - which can be up to 6 days)

source of acute infections is more likely to be the survivors. source of acute infections is more likely to be the survivors.

Human remains only pose health risks in a few special Human remains only pose health risks in a few special cases requiring specific precautions deaths from cholera or cases requiring specific precautions deaths from cholera or haemorrhagic fevers.haemorrhagic fevers.

workers who routinely handle corpses may have a risk of workers who routinely handle corpses may have a risk of contracting contracting tuberculosis, bloodborne viruses (such as tuberculosis, bloodborne viruses (such as Hepatitis B/C and HIV), and gastrointestinal infections (such Hepatitis B/C and HIV), and gastrointestinal infections (such as rotavirus diarrhoea, salmonellosis, E. coli, as rotavirus diarrhoea, salmonellosis, E. coli, typhoid/paratyphoid fevers, hepatitis A, shigellosis and typhoid/paratyphoid fevers, hepatitis A, shigellosis and choleracholera).).

-Tuberculosis :bacillus is aerosolized (residual air in lungs exhaled, -Tuberculosis :bacillus is aerosolized (residual air in lungs exhaled, fluid from lungs spurted up through nose/ mouth during handling of fluid from lungs spurted up through nose/ mouth during handling of the corpse).the corpse).

-bloodborne viruses :direct contact with non-intact skin of blood or -bloodborne viruses :direct contact with non-intact skin of blood or body fluid, injury from bone fragments and needles, or exposure to body fluid, injury from bone fragments and needles, or exposure to the mucous membranes from splashing of blood or body fluid.the mucous membranes from splashing of blood or body fluid.

-Gastrointestinal infections are more common as dead bodies -Gastrointestinal infections are more common as dead bodies commonly leak faeces: occurs via the commonly leak faeces: occurs via the faeco-oral routefaeco-oral route through through direct contact with the body and soiled clothes or contaminated direct contact with the body and soiled clothes or contaminated vehicles or equipment. vehicles or equipment. Dead bodies contaminating the water supplyDead bodies contaminating the water supply may also cause gastrointestinal infections.may also cause gastrointestinal infections.

The public and emergency workers alike should be duly informed to The public and emergency workers alike should be duly informed to avoid panic and inappropriate disposal of bodies, and to take avoid panic and inappropriate disposal of bodies, and to take adequate precautions in handling the dead (see prevention below).adequate precautions in handling the dead (see prevention below).

Other health risks posed Other health risks posed by floodingby flooding

These include drowning and These include drowning and injuries or traumainjuries or trauma. .

TetanusTetanus is is notnot common common after injury from flooding, and mass after injury from flooding, and mass tetanus vaccination programs tetanus vaccination programs are are notnot indicated indicated

tetanus boosters may be indicatedtetanus boosters may be indicated for previously vaccinated for previously vaccinated people who sustain open wounds or for other injured people people who sustain open wounds or for other injured people depending on their tetanus immunization historydepending on their tetanus immunization history

Passive vaccination with tetanus immune globulin (Hypertet) Passive vaccination with tetanus immune globulin (Hypertet) is useful in treating wounded people who have not been is useful in treating wounded people who have not been actively vaccinated and those whose wounds are highly actively vaccinated and those whose wounds are highly contaminated, as well as those with tetanuscontaminated, as well as those with tetanus

HypothermiaHypothermia is a problem in children trapped in floodwaters is a problem in children trapped in floodwaters for lengthy periods. There may also be an increased risk of for lengthy periods. There may also be an increased risk of respiratory tract infections due to exposure (loss of shelter, respiratory tract infections due to exposure (loss of shelter, exposure to flood waters and rain)exposure to flood waters and rain)

Power cuts related to floods may disrupt water treatment and Power cuts related to floods may disrupt water treatment and supply plants supply plants thereby increasing the risk of water-borne thereby increasing the risk of water-borne diseases diseases as described above but may also affect proper as described above but may also affect proper functioning of health facilities, including cold chain.functioning of health facilities, including cold chain.

associated skin diseases during the associated skin diseases during the flood flood

LeptospirosisLeptospirosis

a worldwide zoonotic disease caused by spirochetes of the genus Leptospira. a worldwide zoonotic disease caused by spirochetes of the genus Leptospira.

In Thailand, leptospirosis corresponds with the rainy season, with an increase in In Thailand, leptospirosis corresponds with the rainy season, with an increase in cases beginning in August and decreasing in November; the peak number of cases beginning in August and decreasing in November; the peak number of cases occurs in October *cases occurs in October *

most infections occur in agricultural workers: rice producersmost infections occur in agricultural workers: rice producers

Infection in humans occurs through contact of skin or mucous membranes with Infection in humans occurs through contact of skin or mucous membranes with water or moist soil contaminated with urine of infected animalswater or moist soil contaminated with urine of infected animals

Breaks in skin in facilitate infection, but no previous study has quantified the Breaks in skin in facilitate infection, but no previous study has quantified the correlation between skin wounds and leptospirosis correlation between skin wounds and leptospirosis

Heavy rainfall andHeavy rainfall and flooding flooding; going without shoes; washing in streams; and ; going without shoes; washing in streams; and occupations such as farming, working in sewers, mining, working with animals, occupations such as farming, working in sewers, mining, working with animals, and participating in military activities have all been implicated in human and participating in military activities have all been implicated in human infection infection

Reported cases and morbidity rate (per 100,000 population of leptospiro- sis by year in Thailand, 1995–2000). Vol. 2002: Disease Notification Report, Reported cases and morbidity rate (per 100,000 population of leptospiro- sis by year in Thailand, 1995–2000). Vol. 2002: Disease Notification Report,

Leptosipirosis Control Office; 2000Leptosipirosis Control Office; 2000. .

TextText

Darkfield microscopy of leptospiral microscopic agglutination test.Darkfield microscopy of leptospiral microscopic agglutination test.

Silver stain, liver, fatal human leptospirosisSilver stain, liver, fatal human leptospirosis

Skin manifestation : in anicteric form Skin manifestation : in anicteric form transient ( < 24 transient ( < 24 hrs ) , petechiaehrs ) , petechiae

Ecchynoctic, purpuric skin lesion may occurEcchynoctic, purpuric skin lesion may occur

- Reported erythema nodosumReported erythema nodosum

- Also reported rare complication : Kawasaki syndromeAlso reported rare complication : Kawasaki syndrome

((Emergency DermatologyEmergency Dermatology By Ronni Wolf, Batya B. Davidovici, Jennifer L. Parish) By Ronni Wolf, Batya B. Davidovici, Jennifer L. Parish)

Clinical manifestion: Clinical manifestion:

vary from asymptomatic to severe.vary from asymptomatic to severe.

Some serovars tend to be associated more often with Some serovars tend to be associated more often with some syndromes (e.g., severe disease is often associated some syndromes (e.g., severe disease is often associated with serovar with serovar icterohaem- orrhagiaeicterohaem- orrhagiae))

a biphasic illness.a biphasic illness.

first phasefirst phase, called the acute or septicemic phase, called the acute or septicemic phase

-begins abruptly and lasts approximately : nonspecific signs -begins abruptly and lasts approximately : nonspecific signs including fever, chills, headache and conjunctival suffusion. including fever, chills, headache and conjunctival suffusion. Myalgia, which typically affects the back, thighs or calves, Myalgia, which typically affects the back, thighs or calves, is often severe. is often severe. Occasionally, a transient skin rash occursOccasionally, a transient skin rash occurs..

-Other symptoms may include weakness, photophobia, -Other symptoms may include weakness, photophobia, lymphadenopathy, abdominal pain, nausea, vomiting, a lymphadenopathy, abdominal pain, nausea, vomiting, a sore throat, coughsore throat, cough

- symptoms last for approximately 4 to 9 days, then are - symptoms last for approximately 4 to 9 days, then are typically followed by a 1 to 3 day period during which the typically followed by a 1 to 3 day period during which the temperature drops and the symptoms abate or disappear.temperature drops and the symptoms abate or disappear.

Second phaseSecond phase

-second phase of leptospirosis, called the immune phase, issecond phase of leptospirosis, called the immune phase, is

-characterized by the development of anti-characterized by the development of anti-Lepto- spira Lepto- spira antibodies, and the excretion of the organisms in the urineantibodies, and the excretion of the organisms in the urine

-last up to 30 days or more, but does not develop in all last up to 30 days or more, but does not develop in all patients.patients.

-Nonspecific symptoms seen in the first stage, such as fever Nonspecific symptoms seen in the first stage, such as fever and myalgia, recur but may be less severe than in the first and myalgia, recur but may be less severe than in the first stage of diseasestage of disease

-Two forms of disease, icteric and anicteric, are seen.Two forms of disease, icteric and anicteric, are seen.

The icteric form is more severe. It occurs in 5-10% of all patients, is often The icteric form is more severe. It occurs in 5-10% of all patients, is often rapidly progressive, and may be associ ated with multiorgan failure. The rapidly progressive, and may be associ ated with multiorgan failure. The most commonly involved organ systems are the liver, kidneys and central most commonly involved organ systems are the liver, kidneys and central nervous system (CNS).nervous system (CNS).

Acute renal failure occurs in 16-40% of cases. Acute renal failure occurs in 16-40% of cases.

pulmonary symptoms, with clinical signs ranging from cough, dyspnea, chest pulmonary symptoms, with clinical signs ranging from cough, dyspnea, chest pain, and mild to severe hemoptysis, to adult respiratory distress syndrome.pain, and mild to severe hemoptysis, to adult respiratory distress syndrome.

Cardiac involvement can result in congestive heart failure, myo- carditis and Cardiac involvement can result in congestive heart failure, myo- carditis and pericarditis. pericarditis.

Hemorrhages may also be seen; epistaxis, petechiae, purpura and Hemorrhages may also be seen; epistaxis, petechiae, purpura and ecchymoses are the most common signs, but severe gastrointestinal ecchymoses are the most common signs, but severe gastrointestinal bleeding, adrenal or subarachnoid hemorrhage, and pulmonary hemorrhages bleeding, adrenal or subarachnoid hemorrhage, and pulmonary hemorrhages can occur.can occur.

Rare complications include stroke, rhabdomyolysis, Rare complications include stroke, rhabdomyolysis, thrombotic thrombotic thrombocytopenic purpura, thrombocytopenic purpura, acute acalculous cholecystitisacute acalculous cholecystitis, erythema , erythema nodosumnodosum, aortic stenosis, Kawa- saki syndrome, reactive arthritis, , aortic stenosis, Kawa- saki syndrome, reactive arthritis, epididymitis, nerve palsy, male hypogonadism, Guillain-Barre ‘s syndrome epididymitis, nerve palsy, male hypogonadism, Guillain-Barre ‘s syndrome and cerebral arteritis. and cerebral arteritis.

Deaths can occur from kidney failure, cardiac involvement. Deaths can occur from kidney failure, cardiac involvement. pulmonary hemorrhage or other serious organ dysfunction. pulmonary hemorrhage or other serious organ dysfunction.

Convalescence from the icteric form may take 1-2 months. Convalescence from the icteric form may take 1-2 months.

Although jaundice can persist for weeks, liver function returns to Although jaundice can persist for weeks, liver function returns to normal after recovery, and hepatic disease is rarely the cause of normal after recovery, and hepatic disease is rarely the cause of death. Most patients also recover kidney function.death. Most patients also recover kidney function.

Diagnostic method: Diagnostic method:

by culture, detection of antigens or nucleic acids, or serology.by culture, detection of antigens or nucleic acids, or serology.

Most human cases of leptospirosis Most human cases of leptospirosis are diagnosed by serologyare diagnosed by serology. . The most commonly used serologic tests are the microscopic The most commonly used serologic tests are the microscopic agglutination test (MAT, previously known as the agglutination test (MAT, previously known as the agglutinationlysis test) or ELISAs. agglutinationlysis test) or ELISAs.

MAT test is serogroup but not serovar specific, and can be MAT test is serogroup but not serovar specific, and can be complicated by cross-reactions.complicated by cross-reactions.

TreatmentTreatment

Antibiotics used in humans include Antibiotics used in humans include doxycycline, ampicillin, amoxicillin, penicillin doxycycline, ampicillin, amoxicillin, penicillin and erythromycin. Supportive treatment and and erythromycin. Supportive treatment and management of complications such as renal management of complications such as renal failure, hepatic complications, hemorrhages and failure, hepatic complications, hemorrhages and CNS disease may also be necessary.CNS disease may also be necessary.

Dengue Hemorrhagic Dengue Hemorrhagic FeverFever

The first reported outbreaks of dengue hemorrhagic fever were The first reported outbreaks of dengue hemorrhagic fever were observed in the Philippines in 1953 and 1956.observed in the Philippines in 1953 and 1956.

strongly associated with urban environments and breeding strongly associated with urban environments and breeding of of A. aegypti vectors in domestic water containersA. aegypti vectors in domestic water containers

Humans are considered to be the main reservoir for the virusHumans are considered to be the main reservoir for the virus

Classic dengue begins abruptly after an incubation period of 5 Classic dengue begins abruptly after an incubation period of 5 to 6 days. to 6 days.

Fever may be of the Fever may be of the ““saddlebacksaddleback”” type, in which remission of all type, in which remission of all symptoms occurs after 2 to 3 days, followed by a second phase symptoms occurs after 2 to 3 days, followed by a second phase of mild fever and less severe symptoms last ing 1 to 2 days.of mild fever and less severe symptoms last ing 1 to 2 days.

Flushing of the face and conjunctival injection are commonFlushing of the face and conjunctival injection are common features. features.

An exanthemAn exanthem: tiny glistening vesicles on the soft : tiny glistening vesicles on the soft palate may be seen within 12 hours of onsetpalate may be seen within 12 hours of onset

More often, More often, a morbilliform eruption begins on the a morbilliform eruption begins on the third to fifth day on the inner surfaces of the upper third to fifth day on the inner surfaces of the upper arms, the lateral surface of the thorax, and in the arms, the lateral surface of the thorax, and in the lumbar arealumbar area. The macular or scarlatiniform rash . The macular or scarlatiniform rash spreads to the face, neck, shoulders, and thorax ). spreads to the face, neck, shoulders, and thorax ). Pruritus can occur if the hands and feet are Pruritus can occur if the hands and feet are involved. Cervical lymphadenopathy is frequently involved. Cervical lymphadenopathy is frequently observed. Bradycardia may occur late in the observed. Bradycardia may occur late in the illness and persist through convalescence. illness and persist through convalescence. Recovery often requires 1 to 2 weeks and almost Recovery often requires 1 to 2 weeks and almost invariably is dominated by neurasthenia, mental invariably is dominated by neurasthenia, mental depression, insomnia, and anorexiadepression, insomnia, and anorexia..

Hemorrhagic manifestations of dengue are seen predominantly in Hemorrhagic manifestations of dengue are seen predominantly in children. The symptoms are variable and include petechiae, purpura, children. The symptoms are variable and include petechiae, purpura, oozing from venipuncture and injection sites, gingival bleeding, epistaxis, oozing from venipuncture and injection sites, gingival bleeding, epistaxis, hemoptysis, hematemesis, melena, hematochezia, hematuria, uterine hemoptysis, hematemesis, melena, hematochezia, hematuria, uterine bleeding, and intracranial hemorrhage.bleeding, and intracranial hemorrhage.

Shock can occur after several days of symptoms and is characterized by Shock can occur after several days of symptoms and is characterized by clinical and laboratory signs of hypovolemia. Hemorrhagic manifestations clinical and laboratory signs of hypovolemia. Hemorrhagic manifestations have been reported with all four serotypes.have been reported with all four serotypes.

Laboratory Findings: leukocytosis, atypical lymphocytes, and Laboratory Findings: leukocytosis, atypical lymphocytes, and thrombocytopenia. Dengue virus inhibits marrow proliferation early in the thrombocytopenia. Dengue virus inhibits marrow proliferation early in the course of disease but not in later stages. Although laboratory evidence of course of disease but not in later stages. Although laboratory evidence of disseminated intravascular coagulation can be detected in severe cases disseminated intravascular coagulation can be detected in severe cases of dengue hemorrhagic fever, morphologic evidence is usually found only of dengue hemorrhagic fever, morphologic evidence is usually found only in adolescents and adults. in adolescents and adults.

Coagulation defects include prolongations of the partial thromboplastin Coagulation defects include prolongations of the partial thromboplastin time, prothrombin time, and thrombin time, as well as decreased factors time, prothrombin time, and thrombin time, as well as decreased factors II, V, VII, VIII, IX, and X. Disseminated intravascular coagulation is not II, V, VII, VIII, IX, and X. Disseminated intravascular coagulation is not central to the pathogenesis of dengue hemorrhagic fever, because central to the pathogenesis of dengue hemorrhagic fever, because treatment with heparin has not proved successful.treatment with heparin has not proved successful.

Treatment of dengue hemorrhagic fever is Treatment of dengue hemorrhagic fever is supportive. Live attenuated vaccines are supportive. Live attenuated vaccines are currently being developed. The need for currently being developed. The need for vaccination against all four known serotypes vaccination against all four known serotypes of dengue virus is depen- dent on the relative of dengue virus is depen- dent on the relative risk of developing hemorrhagic disease during risk of developing hemorrhagic disease during subsequent infections with a different subsequent infections with a different serotype.serotype.

study post flood in HADYAI in 2000, among study post flood in HADYAI in 2000, among 180 patients : DHF 29%, Leptospirosis 21%, 180 patients : DHF 29%, Leptospirosis 21%, scrub 1.1% *scrub 1.1% *

MALARIAMALARIA

Plasmodium vivax and P. falciparum occur in about a 20/80 Plasmodium vivax and P. falciparum occur in about a 20/80 ratio in the north and a 50/50 ratio on the peninsularatio in the north and a 50/50 ratio on the peninsula

Humans are the only important reservoir of human malaria.Humans are the only important reservoir of human malaria.

Transmission:Transmission: From the bite of an infective female Anopheles From the bite of an infective female Anopheles mosquito, or from an infectious blood transfusion.mosquito, or from an infectious blood transfusion.

Incubation Period – Usually 12 to 14 days; in some cases P. Incubation Period – Usually 12 to 14 days; in some cases P. vivax may have a protracted incubation period of up to 10 vivax may have a protracted incubation period of up to 10 month.month.

Symptoms :Symptoms :

Acute febrile illness characterized by chills, fever, headache, Acute febrile illness characterized by chills, fever, headache, sweating, muscular ache and general malaise. sweating, muscular ache and general malaise.

P. falciparum symptoms may include severe anemia jaundice, P. falciparum symptoms may include severe anemia jaundice, renal failure, shock, loss of orientation, convulsions and coma. renal failure, shock, loss of orientation, convulsions and coma. Symptoms are most severe in P. falciparum malaria.Symptoms are most severe in P. falciparum malaria.

Thailand probably has the Thailand probably has the worst multiple-drug resistance worst multiple-drug resistance problem in the worldproblem in the world

Some surveys have found nearly 100% of the falciparum Some surveys have found nearly 100% of the falciparum isolates are resistant to isolates are resistant to chloroquinechloroquine

Resistance to Resistance to Fansidar Fansidar (sulfadoxine-pyrimethamine) is also (sulfadoxine-pyrimethamine) is also widespread and resistance to widespread and resistance to quinine, proguanil, halofantrine, quinine, proguanil, halofantrine, and mefloquineand mefloquine is common along the eastern and western is common along the eastern and western borders. borders. Primaquine-tolerant P. vivaxPrimaquine-tolerant P. vivax has been reported from has been reported from southern Thailand.southern Thailand.

Case fatality rates among non-immune adults and children Case fatality rates among non-immune adults and children may approach 10%. Relapses are common with improperly may approach 10%. Relapses are common with improperly treated P. vivax and may occur irregularly for years.treated P. vivax and may occur irregularly for years.

DIAGNOSIS: thick and thin filmDIAGNOSIS: thick and thin film

Thin film: fixed with methanol 10 min Thin film: fixed with methanol 10 min

Thicnk film : not fixedThicnk film : not fixed

Then stain with Giemsa for 5 mins Then stain with Giemsa for 5 mins light light microscopemicroscope

Fever with rashFever with rashEmergency physicians in tsunami relief: a discussion of tsunami-Emergency physicians in tsunami relief: a discussion of tsunami-related health conditions and necessary preparations Hong Kong related health conditions and necessary preparations Hong Kong

j.emerg.med. 2005;12:252-260)j.emerg.med. 2005;12:252-260)

As outbreaks of As outbreaks of meningococcal meningitismeningococcal meningitis occur from occur from time to time, the possibility of meningococcaemia time to time, the possibility of meningococcaemia should be carefully considered for patients presenting should be carefully considered for patients presenting with fever and rash. Twith fever and rash. T

he likelihood of meningococcaemia increases if the he likelihood of meningococcaemia increases if the patient has recently travelled from the"meningitis belt" patient has recently travelled from the"meningitis belt" in Africa (a region of savannah that extends from in Africa (a region of savannah that extends from Ethiopia in East Africa to Senegal in West Africa).In the Ethiopia in East Africa to Senegal in West Africa).In the case of meningococcaemia, the case of meningococcaemia, the rash is rash is characteristically petechial, small and irregular with characteristically petechial, small and irregular with "smudged" appearance, and is often raised with pale "smudged" appearance, and is often raised with pale greyish vesicular centres. It is commonly located on the greyish vesicular centres. It is commonly located on the extremities and the trunk.extremities and the trunk.

meningococcaemiameningococcaemia

In the case of In the case of typhoid fevertyphoid fever, the , the rose spots rose spots will appear as slightly will appear as slightly raised, non-tender, pink papules that blanch on pressure. They raised, non-tender, pink papules that blanch on pressure. They usually appear in crops of 10 to 20 lesions and are often located usually appear in crops of 10 to 20 lesions and are often located between the nipple area and the umbilicus on the anterior trunk.between the nipple area and the umbilicus on the anterior trunk.

In the case of In the case of leptospirosisleptospirosis, skin lesions usually appear on the , skin lesions usually appear on the trunk and take the form of macules, papules, urticaria and trunk and take the form of macules, papules, urticaria and petechiae.petechiae.

In the case of In the case of denguedengue, skin eruptions appear in 80% of patients , skin eruptions appear in 80% of patients during the remission of fever. They may appear as centrifugal during the remission of fever. They may appear as centrifugal macular, maculopapular, scarlatiniform or petechial eruptions. macular, maculopapular, scarlatiniform or petechial eruptions. The eruptions may become confluent with small round islands of The eruptions may become confluent with small round islands of sparing, the so-called white islands in a sea of red. The sparing, the so-called white islands in a sea of red. The rash rash characteristically starts on the dorsum of hands and feet and characteristically starts on the dorsum of hands and feet and spreads to the arms, legs, and torso, while the face is relatively spreads to the arms, legs, and torso, while the face is relatively sparedspared. The eruption seen in dengue lasts two hours to several . The eruption seen in dengue lasts two hours to several days.days.

leptospirosis rash:Early in the disease, the skin leptospirosis rash:Early in the disease, the skin is warm and flushed. Additional skin findings is warm and flushed. Additional skin findings include a transient petechial eruption that can include a transient petechial eruption that can involve the palate. Later in severe disease, involve the palate. Later in severe disease, jaundice and purpura can develop.jaundice and purpura can develop.

ROSE SPOT: TYPHOID FEVERROSE SPOT: TYPHOID FEVER

Viral haemorrhagic fever Viral haemorrhagic fever is an acute illness due to is an acute illness due to infection by four viral families: infection by four viral families: Arenaviridae, Arenaviridae, Bunyaviridae, Filoviridae and FlaviviridaeBunyaviridae, Filoviridae and Flaviviridae. They fall in the . They fall in the same group because of the common underlying same group because of the common underlying pathophysiology. They all attack the vascular bed with pathophysiology. They all attack the vascular bed with resultant microvascular damage and changes in vascular resultant microvascular damage and changes in vascular permeability. They are usually transmitted by contact permeability. They are usually transmitted by contact with the natural reservoirs, e.g. mosquitoes, ticks, or with the natural reservoirs, e.g. mosquitoes, ticks, or rodents. Flaviviridae can be found in the entire tropical rodents. Flaviviridae can be found in the entire tropical zone, including India and Southeast Asiazone, including India and Southeast Asia

For patients with septicaemic plague, they may present For patients with septicaemic plague, they may present with purpuric skin lesions, together with gangrene of acral with purpuric skin lesions, together with gangrene of acral regions leading to "Black Death"regions leading to "Black Death"

Immersion Foot syndromeImmersion Foot syndrome(JOHN ADNOT, M.D.* AND CHARLES W. LEWIS, M.D., (JOHN ADNOT, M.D.* AND CHARLES W. LEWIS, M.D., IMMERSION FOOT IMMERSION FOOT

SYNDROMES, Military dermatology)SYNDROMES, Military dermatology)

Injuries to the feet from prolonged immersion Injuries to the feet from prolonged immersion in water or contact with dampness, in a range in water or contact with dampness, in a range of envi- ronmental temperatures, may be of envi- ronmental temperatures, may be collectively re- ferred to as “immersion foot collectively re- ferred to as “immersion foot syndromes.”syndromes.”

Cold weather (< 15 C): trench foot, Cold weather (< 15 C): trench foot, immersion footimmersion foot

Warmer weather (22-32 C) : Warmer weather (22-32 C) : Tropical Tropical immersion foot, immersion foot, Warm water immersion footWarm water immersion foot

Tropical Immersion Tropical Immersion FootFoot

warmer environment in troops fight- ing in the Philippines warmer environment in troops fight- ing in the Philippines during World War IIduring World War II

known as known as “paddy foot” “paddy foot”

continuous or near-continuous immersion continuous or near-continuous immersion of the foot in water of the foot in water or mud of temperatures above 22°C for periods ranging from 2 or mud of temperatures above 22°C for periods ranging from 2 to 10 daysto 10 days

Site : Dorsum of foot, anklesSite : Dorsum of foot, ankles

When footgear is removedWhen footgear is removed feet may initially appear pale, feet may initially appear pale, but they rapidly become intensely erythematous in a but they rapidly become intensely erythematous in a distribution sharply demarcated at shoe- or boot- top level distribution sharply demarcated at shoe- or boot- top level

This erythema affects the dorsum of the foot but This erythema affects the dorsum of the foot but notnot the the plantar surfacesplantar surfaces——an important differentiating point from an important differentiating point from warmwaterimmersionfootwarmwaterimmersionfoot

Papules,vesicles, or both may appear, Papules,vesicles, or both may appear, sometimes with a hemorrhagic componentsometimes with a hemorrhagic component

Severely affected soldiers have tender Severely affected soldiers have tender unilateral or bilateral femoral adenopathy and unilateral or bilateral femoral adenopathy and a fever a fever of 38°C to 39°C.of 38°C to 39°C.

Histology: epidermal parakeratosis and Histology: epidermal parakeratosis and acanthosis, dermal edema and telangiectasia, acanthosis, dermal edema and telangiectasia, and a lymphocytic perivascular infiltrate with and a lymphocytic perivascular infiltrate with associated extravasation of RBCassociated extravasation of RBC

changes are caused by loss of barrier function of the swollen changes are caused by loss of barrier function of the swollen stratum corneum, with secondary irritation or damage to the stratum corneum, with secondary irritation or damage to the underlying tissuesunderlying tissues

Management :Management :

bed rest, elevating and drying the feet, analgesics ifbed rest, elevating and drying the feet, analgesics if necessary ,and antibiotics if indicatednecessary ,and antibiotics if indicated

fever and adenopathy resolve within 72 hoursfever and adenopathy resolve within 72 hours

erythema and edema subside in 5 to 7 days erythema and edema subside in 5 to 7 days fine branny fine branny desquamation resulting in normal-appearing feetdesquamation resulting in normal-appearing feet

most severe cases usually resolve within 2 weeks without most severe cases usually resolve within 2 weeks without sequelae such as gangrene, persistent sensory changes, sequelae such as gangrene, persistent sensory changes, ororthopedic disability ororthopedic disability

PreventionPrevention

24-hour drying-out period 24-hour drying-out period alternated with alternated with each 48 hours of water exposure. each 48 hours of water exposure.

rapid-drying boots and socks may delay the rapid-drying boots and socks may delay the onset of tropical immersion onset of tropical immersion

silicone greases used as a barrier ointment silicone greases used as a barrier ointment have not proved effective. have not proved effective.

Warm Water Warm Water Immersion FootImmersion Foot

““moon-boot syndrome.”moon-boot syndrome.”

intermittent intermittent exposure to wet, warm conditionsexposure to wet, warm conditions

1 to 3 days of exposure: note 1 to 3 days of exposure: note pain on weight pain on weight bearing, tingling described as “walking on ropebearing, tingling described as “walking on rope.”.”

When footwear is removed, the soles of the feet When footwear is removed, the soles of the feet are thickened, severely wrinkled, and maceratedare thickened, severely wrinkled, and macerated

changes may extend to the sides of the foot, changes may extend to the sides of the foot, they do they do not affect the dorsumnot affect the dorsum

Warm water immersion foot appears to develop faster at Warm water immersion foot appears to develop faster at higher water temperatures higher water temperatures

Histology: hyperhydration of the stratum corneum is the only Histology: hyperhydration of the stratum corneum is the only finding (thickening of stratum corneum)finding (thickening of stratum corneum)

Treatment Treatment

bed rest anddrying the feetbed rest anddrying the feet

Wrinkles andWrinkles and macerationmaceration resolveresolve within 24 hours, but within 24 hours, but tenderness may last 2 to 3 days.tenderness may last 2 to 3 days.

The patient is asymptomatic by the third day. Shortly The patient is asymptomatic by the third day. Shortly thereafter, howeverthereafter, however, thick portions of the sole begin to fissure , thick portions of the sole begin to fissure and peel, shedding completely within 1 to 2 weeksand peel, shedding completely within 1 to 2 weeks. During . During this peeling, the stratum corneum may be more susceptible this peeling, the stratum corneum may be more susceptible to infection via the fissuresto infection via the fissures

PreventionPrevention

drying the feet for 6 to 8 hours (overnight) of every 24 drying the feet for 6 to 8 hours (overnight) of every 24 hours. hours.

Silicone grease applied to the entire foot or to the soles Silicone grease applied to the entire foot or to the soles aloneretards the development of warm water immersion aloneretards the development of warm water immersion foot.foot.

Footgear with adequate drainage and composed of Footgear with adequate drainage and composed of rapidly drying materials may also slow the development rapidly drying materials may also slow the development of this conditionof this condition

Trench footTrench foot

Skin Diseases during Floods in ThailandSkin Diseases during Floods in ThailandJ Med Assoc Thai Vol. 91 No. 4 2008J Med Assoc Thai Vol. 91 No. 4 2008

In September 2006, a major flood occurred in In September 2006, a major flood occurred in northern, northeastern and central parts of Thailand northern, northeastern and central parts of Thailand and included 47 provinces. Approximately 3.1 million and included 47 provinces. Approximately 3.1 million Thai people were affected badly from this catastropheThai people were affected badly from this catastrophe

most common skin diseases during floods and identify most common skin diseases during floods and identify the organism that causes skin maceration at web the organism that causes skin maceration at web space(s) of toes : space(s) of toes : Hong kong footHong kong foot

Infectious dermatoses were the second most common Infectious dermatoses were the second most common skin problems. Superficial fungal infection and skin problems. Superficial fungal infection and bacterial skin infection were accounted for in most bacterial skin infection were accounted for in most cases. cases.

Ninety-six patients were evaluated by two dermatologists in the Ninety-six patients were evaluated by two dermatologists in the present study (58 females and 38 males) with 102 skin conditions. present study (58 females and 38 males) with 102 skin conditions. The ages of the patients ranged from 2 to 81 years, with a median The ages of the patients ranged from 2 to 81 years, with a median

age of 46 years. The study was doneage of 46 years. The study was done in both Singhaburi and Utaithani provinces during October 2006. in both Singhaburi and Utaithani provinces during October 2006.

-Gram negative bacilli, -Gram negative bacilli, Coryne- bacterium Coryne- bacterium and and Staphylococcus Staphylococcus species were found in 14, 4 and 4 specimens respectively.species were found in 14, 4 and 4 specimens respectively.- fungal culture showed two (out of 16) positive specimens. They - fungal culture showed two (out of 16) positive specimens. They were were Trichosporon mucoides Trichosporon mucoides and non-spore forming hyaline fungi and non-spore forming hyaline fungi

In Summary, the authors concluded that eczema was the In Summary, the authors concluded that eczema was the most common skin problem during the period of the flood. most common skin problem during the period of the flood.

Skin maceration at web space(s) of toes which were thought Skin maceration at web space(s) of toes which were thought to be fungal infection were chronic irritant dermatitis with to be fungal infection were chronic irritant dermatitis with secondary bacterial colonization. secondary bacterial colonization.

Excessive exposure to contaminated water, friction, high Excessive exposure to contaminated water, friction, high humidity and unhygienic environment might have increased humidity and unhygienic environment might have increased the prevalence of bacterial colonization on eczematous the prevalence of bacterial colonization on eczematous macerated skin.macerated skin.

Microbiologic investiga- tion should be done in patients who Microbiologic investiga- tion should be done in patients who complain of skin maceration at web space(s) of toecomplain of skin maceration at web space(s) of toe

medications which have the combination of anti- medications which have the combination of anti- inflammatory, antibacterial and antifungal properties are inflammatory, antibacterial and antifungal properties are the most suitable medications.the most suitable medications.

Occlusion, carbon dioxide, Occlusion, carbon dioxide, andand fungal skin infectionsfungal skin infections

((Allen AM, King RDAllen AM, King RD. Occlusion, carbon dioxide, and. Occlusion, carbon dioxide, and fungal skin infections.fungal skin infections. Lancet. 1978 Feb 18;1(8060):360-2.Lancet. 1978 Feb 18;1(8060):360-2.))

OcclusionOcclusion of the skin has the profound effect in producing, aggravating or of the skin has the profound effect in producing, aggravating or treating various skin diseasestreating various skin diseases

the prevalence and severity of inflammatory the prevalence and severity of inflammatory Trichphyton mentagrophytes Trichphyton mentagrophytes (ringworm) infection among US troop in Vietnam were directly related to (ringworm) infection among US troop in Vietnam were directly related to occlusion of the skin by wet clothingocclusion of the skin by wet clothing

CO2 tension on skin surface are usually well below those required to CO2 tension on skin surface are usually well below those required to induce arthrospore formation in vitroinduce arthrospore formation in vitro

When skin is occluded with wet clothing, thin Teflonn sheet, plastic tape When skin is occluded with wet clothing, thin Teflonn sheet, plastic tape Or in intertriginous area Or in intertriginous area raise surface Co2 tension : same distribution of raise surface Co2 tension : same distribution of dermatophyte and candidal infectiondermatophyte and candidal infection

Trichphyton mentagrophytes Trichphyton mentagrophytes infection provide the best support for infection provide the best support for hypothesis because of their diversityhypothesis because of their diversity

T. rubrum, T. concentrigum, E. floccosum and C. albicanT. rubrum, T. concentrigum, E. floccosum and C. albican

Produce experimental human skin infection in rge preence of occlusionProduce experimental human skin infection in rge preence of occlusion

T. rubrum, and T.T. rubrum, and T. mentagrophytes mentagrophytes has grunular, sporulating has grunular, sporulating morphological phase which is associated with more virulencemorphological phase which is associated with more virulence

These postulated relations ( occlusion+ Co2 tension+ infectivity These postulated relations ( occlusion+ Co2 tension+ infectivity of dermatophyte) lead to prevention and control strategiesof dermatophyte) lead to prevention and control strategies

-removal occlusive merterial from the skin-removal occlusive merterial from the skin

- Application of substances those interfere with action of CO2Application of substances those interfere with action of CO2

-development of clothing which would be non-occlusive when wet-development of clothing which would be non-occlusive when wet

Cercarial DermatitisCercarial Dermatitis

First describe in 1928 by CortFirst describe in 1928 by Cort

Associated with all types of water such as rice Associated with all types of water such as rice fields, ponds, streams, canals, river and seafields, ponds, streams, canals, river and sea

Commonly found in bodies of water with Commonly found in bodies of water with many water plants, snails and domestic many water plants, snails and domestic animals such as cows, ducks, and water animals such as cows, ducks, and water buffalosbuffalos

Caused by schistosome cercaria, a blood flukeCaused by schistosome cercaria, a blood fluke

Types those be able to penetrate human skin and cause Types those be able to penetrate human skin and cause the rash : Trichobilharzia and Schistosoma spindalethe rash : Trichobilharzia and Schistosoma spindale

Types of snail as intermediate hosts are Lymneaea and Types of snail as intermediate hosts are Lymneaea and IndoplanorbisIndoplanorbis

Symptoms occur when cercariae penetrate and release Symptoms occur when cercariae penetrate and release histolytic enzyme histolytic enzyme immediate lesion immediate lesion

Delayed type hypersensitivity to protiens from cercariae Delayed type hypersensitivity to protiens from cercariae in epidermis in epidermis 10-15 hrs 10-15 hrs

Erythematous papules Erythematous papules 2 weeks faded with PIH 2 weeks faded with PIH

Cercariae could live only 1 day after emerging Cercariae could live only 1 day after emerging from snailsfrom snails

Eosinophilia 30 % ( normal in hoorworm)Eosinophilia 30 % ( normal in hoorworm)

Kullavanijaya P, Wongwaisayawan H. Outbreak Kullavanijaya P, Wongwaisayawan H. Outbreak of cercarial dermatitis inof cercarial dermatitis inThailand. Int J Thailand. Int J Dermatol. 1993 Feb;32(2):113-5 Dermatol. 1993 Feb;32(2):113-5 … was … was published due to a heavy and prolong flooding published due to a heavy and prolong flooding in Thailand in 1993in Thailand in 1993

LeechLeechClass HirudineaClass Hirudinea

• Most leeches are active predators; however, some are the Most leeches are active predators; however, some are the parasitic, bloodsucking forms.parasitic, bloodsucking forms.

• Blood suckers have blade like jaws that they use to Blood suckers have blade like jaws that they use to penetrate the skin of a host.penetrate the skin of a host.

• Blood is prevented from clotting because they secrete a Blood is prevented from clotting because they secrete a powerful anticoagulant; anesthetics are also released: powerful anticoagulant; anesthetics are also released: hirudinhirudin, antihistamine, antihistamine

• A muscular pharynx subsequently pumps blood into the gutA muscular pharynx subsequently pumps blood into the gut

Leeches are classified in the phylum Annelida (segmented Leeches are classified in the phylum Annelida (segmented worms).worms).

Fresh-water leeches were used in bloodletting in Europe in Fresh-water leeches were used in bloodletting in Europe in the 18th and 19th centuries the 18th and 19th centuries

several species of leeches were used, the several species of leeches were used, the medicinal leech, medicinal leech, Hirudo medicinalisHirudo medicinalis, was the most popular. , was the most popular.

H. medicinalis H. medicinalis may measure about 12cm when fully may measure about 12cm when fully extended. The body tapers towards each extremity, where it extended. The body tapers towards each extremity, where it is provided with a muscular disc or sucker. Within the anterior is provided with a muscular disc or sucker. Within the anterior sucker is the mouth, bordered by three jawssucker is the mouth, bordered by three jaws

Leeches attach themselves to the skin using these powerful Leeches attach themselves to the skin using these powerful jaws, and feed until engorged, when they release their grip jaws, and feed until engorged, when they release their grip and drop to the groundand drop to the ground

Their saliva possesses anticoagulant, fibrinolytic, vasodilator Their saliva possesses anticoagulant, fibrinolytic, vasodilator and probably also anaesthetic propertiesand probably also anaesthetic properties

(Rook’s Textbook of Dermatology(Rook’s Textbook of Dermatology, 8th edition ch. , 8th edition ch. 38.55)38.55)

Some of the substances introduced by leeches during feeding Some of the substances introduced by leeches during feeding are antigenic, and if sensitization to these substances are antigenic, and if sensitization to these substances develops the reaction to the bite may be urticarial or bullous develops the reaction to the bite may be urticarial or bullous

Multiple pseudolymphomas have occurred following Multiple pseudolymphomas have occurred following application of leeches to the legs application of leeches to the legs

Unfortunately, the use of leeches carries the risk of Unfortunately, the use of leeches carries the risk of introducing wound infection, most frequently with introducing wound infection, most frequently with Aeromonas Aeromonas hydrophilahydrophila, a Gram-negative rod, but occasionally other , a Gram-negative rod, but occasionally other organisms are involvedorganisms are involved

Aeromonas Aeromonas is part of the normal gut flora of the leech, where is part of the normal gut flora of the leech, where it is thought to be essential to aid digestion of a blood meal, it is thought to be essential to aid digestion of a blood meal, as proteolytic enzymes are virtually absent from the leech as proteolytic enzymes are virtually absent from the leech gut. Many plastic surgeons who use leeches employ antibiotic gut. Many plastic surgeons who use leeches employ antibiotic prophylaxis to protect against wound infection.prophylaxis to protect against wound infection.

International reported International reported articlesarticles

Leishmaniasis Leishmaniasis Maryam Baqir et al./Asian Pacific Journal of Tropical Maryam Baqir et al./Asian Pacific Journal of Tropical

Biomedicine (2012)76-79Biomedicine (2012)76-79

caused by Leishmania spp transmitted by the sand flycaused by Leishmania spp transmitted by the sand fly

lead to deep, disfiguring sores at the site of the bite, which are lead to deep, disfiguring sores at the site of the bite, which are more likely on the exposed parts of the body.more likely on the exposed parts of the body.

Systemic or visceral leishmaniasis which is rarer in Pakistan Systemic or visceral leishmaniasis which is rarer in Pakistan affects the internal body organs, particularly the spleen and affects the internal body organs, particularly the spleen and liverliver

endemic in Pakistan and Afghanistan, and its incidence has endemic in Pakistan and Afghanistan, and its incidence has been risingbeen rising

Outbreaks have been seen in refugee settlements along the Outbreaks have been seen in refugee settlements along the north-western border of Pakistan during the Afghani crisisnorth-western border of Pakistan during the Afghani crisis

Poor sanitation and malnutrition also help spread the disease Poor sanitation and malnutrition also help spread the disease by providing a habitat for the sand fly and lowering the general by providing a habitat for the sand fly and lowering the general health of the population, making them more susceptible.health of the population, making them more susceptible.

Leishmaniasis is hence common in overcrowded, poverty Leishmaniasis is hence common in overcrowded, poverty stricken stricken

Floods can potentially increase the transmission of Floods can potentially increase the transmission of leishmaniasis. Bihar, a region in India endemic to floods, leishmaniasis. Bihar, a region in India endemic to floods, has seen a surge in the disease since 1977.has seen a surge in the disease since 1977.

As the relief efforts in flood-hit Pakistan intensify, As the relief efforts in flood-hit Pakistan intensify, officials should brace themselves for an outbreak of officials should brace themselves for an outbreak of leishmaniasisleishmaniasis

Residual insecticide spray and impregnated bed nets Residual insecticide spray and impregnated bed nets are effective. Even more important, however, is are effective. Even more important, however, is improving environmental and sanitation living improving environmental and sanitation living conditions.conditions.

Wound infections and Wound infections and sources of infectionsources of infection

Whenever skin integrity is breached, the Whenever skin integrity is breached, the normal flora colonizing the skin can become normal flora colonizing the skin can become source of infection. These include source of infection. These include staphylococcal and streptococcal species, staphylococcal and streptococcal species, with aggressive infections typically caused by with aggressive infections typically caused by Staphylococcus aureus Staphylococcus aureus and and Streptococcus Streptococcus pyogenes pyogenes (Group A streptococcus)(Group A streptococcus). But in one . But in one study, study, gram-positive cocci were uncommon gram-positive cocci were uncommon causes of wound infections in tsunami causes of wound infections in tsunami survivors.survivors.

Fresh and seawater Fresh and seawater pathogenspathogens

Bacteria classically associated with freshwater Bacteria classically associated with freshwater exposure are gram-negative bacilli such as exposure are gram-negative bacilli such as AeromonasAeromonas, , Plesiomonas Plesiomonas and and PseudomonasPseudomonas. . Atypical mycobacteria may also be seen in Atypical mycobacteria may also be seen in wounds with freshwater exposure. wounds with freshwater exposure. Mycobacterium marinum Mycobacterium marinum or occasionally, other or occasionally, other rapid growers , may form granulomatous rapid growers , may form granulomatous infections with infections with a sporotrichoid pattern.a sporotrichoid pattern.

In In ThailandThailand, the , the most common organisms most common organisms isolated from wound infection were isolated from wound infection were Aeromonas Aeromonas speciesspecies

Most isolates were Most isolates were susceptible to aminoglycoside, susceptible to aminoglycoside, third- and fourth-generation cephalosporin, quinolone, third- and fourth-generation cephalosporin, quinolone, and imipeand imipenem but were resistant to amoxicillin- nem but were resistant to amoxicillin- clavulanate and first-generation cephalosporinclavulanate and first-generation cephalosporin

85% of isolates of gram-negative bacilli were sensitive 85% of isolates of gram-negative bacilli were sensitive to aminoglycosides, third- and fourth-generation to aminoglycosides, third- and fourth-generation cephalosporins, quinolones, and imipenem.cephalosporins, quinolones, and imipenem.

Most isolates of Most isolates of Aeromonas Aeromonas species, species, P. aeruginosaP. aeruginosa, , and and Proteus Proteus species were resistant to first- generation species were resistant to first- generation cephalosporins and amoxicillin-clavulanate.3cephalosporins and amoxicillin-clavulanate.3

Vibrio vulnificus Vibrio vulnificus can cause wound infections in can cause wound infections in patients whose wound are exposed to seawaterpatients whose wound are exposed to seawater

Other Other Vibrio Vibrio species seen infrequently in connection species seen infrequently in connection with marine exposure are with marine exposure are V. alginolyticus V. alginolyticus and and V. V. parahaemolyticusparahaemolyticus. .

Vibrio Vibrio infections should respond to quinolone, or infections should respond to quinolone, or ceftazidime plus doxycycline. It has been reported ceftazidime plus doxycycline. It has been reported that Vibrio sp had 1.6% of total wound infections that Vibrio sp had 1.6% of total wound infections culturedcultured

Soil pathogensSoil pathogens

AnaerobesAnaerobes bacteria are commonly encountered in bacteria are commonly encountered in wound infection contaminated by soil. Metronidazole wound infection contaminated by soil. Metronidazole and clindamycin possess the added virtue of excellence and clindamycin possess the added virtue of excellence oral bio-availability with activity against anaerobic oral bio-availability with activity against anaerobic bacteria.bacteria.

Skin abrasions even superficial cuts, can provide Skin abrasions even superficial cuts, can provide potential portal of entry for potential portal of entry for Clostridium tetaniClostridium tetani, the , the gram-positive rod. TIG 500 to 3000 IU, initiating active gram-positive rod. TIG 500 to 3000 IU, initiating active immunization with tetanus vaccine, and supportive immunization with tetanus vaccine, and supportive care. Oral metronidazole therapy may be superior to care. Oral metronidazole therapy may be superior to intramuscular penicillin; other antibiotics with activity intramuscular penicillin; other antibiotics with activity against against C. tetani C. tetani include cephalosporins, macrolides and include cephalosporins, macrolides and imipenemimipenem

Burkholderia pseudomallei Burkholderia pseudomallei ::soil-associated organism soil-associated organism endemic in southeast Asia. endemic in southeast Asia.

Cutaneous injuries resulting from inoculation of the Cutaneous injuries resulting from inoculation of the pathogen can lead to pathogen can lead to cutaneous meliodosis cutaneous meliodosis as well as as well as septicemic meliodosis. Other co- isolated organisms septicemic meliodosis. Other co- isolated organisms included included Pseudomonas aeruginosa Pseudomonas aeruginosa and and Klebsiella Klebsiella sp.sp.

MucormycosisMucormycosis has previously been reported in wound has previously been reported in wound infection from trauma and natural disasters. The report of infection from trauma and natural disasters. The report of posttraumatic cutaneous mucormycosis in Australian posttraumatic cutaneous mucormycosis in Australian traveler who was injured in Sri Lanka during the tsunami traveler who was injured in Sri Lanka during the tsunami is consistent with likely soil contamination of his wounds. is consistent with likely soil contamination of his wounds. Diagnosis was made on histopathology showing tissue Diagnosis was made on histopathology showing tissue invasion, and fungal culture subsequently grew invasion, and fungal culture subsequently grew Aphophysomyces elegansAphophysomyces elegans. Treatment in his case . Treatment in his case consisted of surgical debridement, amphoterincin B consisted of surgical debridement, amphoterincin B (liposomal) and adjunctive hyperbaric oxygen therapy.(liposomal) and adjunctive hyperbaric oxygen therapy.

Sewage and faecal Sewage and faecal pathogenspathogens

gram-negative coliforms, such as gram-negative coliforms, such as Escherichia colEscherichia coli i and and ProteusProteus and and Klebsiella Klebsiella species. Third-generation species. Third-generation cephalosporin or quinolone may be used empirically until cephalosporin or quinolone may be used empirically until susceptibility testing is available. In one report, susceptibility testing is available. In one report, Escherichia coli Escherichia coli was 18.1% of all wound infection culturedwas 18.1% of all wound infection cultured

Rat biteRat bite, although uncommon, may pose a problem in , although uncommon, may pose a problem in some area. These injuries are a risk for rare organisms some area. These injuries are a risk for rare organisms such as such as Spirillum minus Spirillum minus and and Streptobacillus moniliformisStreptobacillus moniliformis, , which has been described to cause fulminant illness even which has been described to cause fulminant illness even in healthy persons. Antibiotic treatment includes in healthy persons. Antibiotic treatment includes amoxycilin/clavulanate or doxycycline.amoxycilin/clavulanate or doxycycline.

For patients whose For patients whose traumatic wounds traumatic wounds are are deep, heavily contaminated, located on the deep, heavily contaminated, located on the lower body, and/or have a foul-smelling lower body, and/or have a foul-smelling discharge, the possibility discharge, the possibility of mixed infection of mixed infection with aerobic gram-positive cocci, aerobic with aerobic gram-positive cocci, aerobic gram negative bacilli from fecal bacteria, and gram negative bacilli from fecal bacteria, and anaerobes should be considered.anaerobes should be considered.

Noe R, Cohen AL, Lederman E, Gould LH, Alsdurf H, Vranken P, Noe R, Cohen AL, Lederman E, Gould LH, Alsdurf H, Vranken P,

Ratard R, Morgan J, Norton SA, Mott JRatard R, Morgan J, Norton SA, Mott J..

Skin disorders among construction Skin disorders among construction workers followingworkers following

Hurricane Katrina and Hurricane Rita: an Hurricane Katrina and Hurricane Rita: an outbreak investigation in New Orleans,outbreak investigation in New Orleans,

Louisiana. Louisiana.

Arch Dermatol. 2007 Nov;143(11):1393-8.Arch Dermatol. 2007 Nov;143(11):1393-8.

PAPULAR URTICARIA

BACTERIAL FOLLICULITISBACTERIAL FOLLICULITIS

Fiberglass DermatitisFiberglass Dermatitis

diagnosis was made among those workers diagnosis was made among those workers who manifested poorly demarcated diffuse who manifested poorly demarcated diffuse erythema with urticarial, sandpa- pery, or erythema with urticarial, sandpa- pery, or morbilliform texture, predominantly on the morbilliform texture, predominantly on the volar aspects of the forearms, with intense volar aspects of the forearms, with intense pruritus that began within 4 hours of exposure pruritus that began within 4 hours of exposure of handling fiberglassof handling fiberglass

Brachioradial Brachioradial PhotodermatitisPhotodermatitis

((Walcyk PJ, Elpern DJ. Brachioradial pruritus: a tropical dermopathy. Br J Dermatol. 1986;115(2):177-180Walcyk PJ, Elpern DJ. Brachioradial pruritus: a tropical dermopathy. Br J Dermatol. 1986;115(2):177-180))

Brachioradial pruritus was first reporteded by Brachioradial pruritus was first reporteded by Waisman 1968Waisman 1968

who termed it solar pruritus of the elbows, who termed it solar pruritus of the elbows, describing its occurrence in patients in Florida describing its occurrence in patients in Florida who showed a localized itch of the skin on the who showed a localized itch of the skin on the dorso-lateral aspect of the armdorso-lateral aspect of the arm

brachioradial pruritus is a photo- neurological brachioradial pruritus is a photo- neurological disorder caused by sun-induced damage to disorder caused by sun-induced damage to nerve endings that results in pruritus and nerve endings that results in pruritus and altered sensation in susceptible individualsaltered sensation in susceptible individuals

On the other hand, Hail in South Africa, On the other hand, Hail in South Africa, suggested that brachioradial pruritus may be suggested that brachioradial pruritus may be caused by nerve injury to the cervical spine or caused by nerve injury to the cervical spine or by nerve compression at other locations by nerve compression at other locations because 5 out of his 14 patients had a history because 5 out of his 14 patients had a history of neck trauma or arthritisof neck trauma or arthritis

West Nile virusWest Nile virus

West Nile virus causes sporadic cases and outbreaks of West Nile virus causes sporadic cases and outbreaks of human and equine disease in Europe (western human and equine disease in Europe (western Mediterranean and southern Russia in 1962-64, Mediterranean and southern Russia in 1962-64, Belarus and Ukraine in the 1970s and 1980s, Romania Belarus and Ukraine in the 1970s and 1980s, Romania in 1996-97, Czechland in 1997, and Italy in 1998)in 1996-97, Czechland in 1997, and Italy in 1998)

Environmental factors, including human activities, Environmental factors, including human activities, that enhance population densities of vector that enhance population densities of vector mosquitoes (heavy rains followed mosquitoes (heavy rains followed by floodsby floods, irrigation, , irrigation, higher than usual temperature, or formation of higher than usual temperature, or formation of ecologic niches that enable mass breeding of ecologic niches that enable mass breeding of mosquitoes) could increase the incidence of West Nile mosquitoes) could increase the incidence of West Nile fever.fever.

West Nile virus is a member of the Japanese West Nile virus is a member of the Japanese encephalitis antigenic complex of the encephalitis antigenic complex of the genus Flavivirus, genus Flavivirus, family Flaviviridaefamily Flaviviridae

transmissible by mosquitoes and many of them can transmissible by mosquitoes and many of them can cause febrile, sometimes fatal, illnesses in humanscause febrile, sometimes fatal, illnesses in humans

first isolated from the blood of a febrile woman in the first isolated from the blood of a febrile woman in the West Nile district of Uganda in 1937 (5) and was West Nile district of Uganda in 1937 (5) and was subsequently isolated from patients, birds, and subsequently isolated from patients, birds, and mosquitoes in Egypt in the early 1950s (6-7). The virus mosquitoes in Egypt in the early 1950s (6-7). The virus was soon recognized as the most widespread of the was soon recognized as the most widespread of the flaviviruses, with geographic distribution in- cluding flaviviruses, with geographic distribution in- cluding Africa and EurasiaAfrica and Eurasia

Ann Intern Med. Ann Intern Med. 2002;137:173-179.2002;137:173-179.

Reported : MP rash

Ann Intern Med. 2002;137:173-179.Ann Intern Med. 2002;137:173-179.

Buruli ulcerBuruli ulcerMycobacterium ulcerans Mycobacterium ulcerans

DiseaseDisease M. ulcerans infection has occurred only after significant M. ulcerans infection has occurred only after significant

environmental disturbanceenvironmental disturbance

In the original paper describing the disease, published in 1948, In the original paper describing the disease, published in 1948, the first patients from the Bairnsdale district in Australia the first patients from the Bairnsdale district in Australia presented in 1939 presented in 1939

In December 1935, there had been the worst floods on record in In December 1935, there had been the worst floods on record in the district, when all road and rail links had been cut and much the district, when all road and rail links had been cut and much property destroyedproperty destroyed

In Uganda, Barker examined cases of M. ulcerans in the Busoga In Uganda, Barker examined cases of M. ulcerans in the Busoga district on the east side of the Victoria Nile, north of Lake Victoria district on the east side of the Victoria Nile, north of Lake Victoria

Barker postulated that the outbreak was related to Barker postulated that the outbreak was related to unprecedented flooding of the lakes of Uganda between 1962 unprecedented flooding of the lakes of Uganda between 1962 and 1964 as a result of heavy rainfalland 1964 as a result of heavy rainfall

it has been hypothesized63 that it has been hypothesized63 that M ulcerans M ulcerans resides in soil resides in soil as a contaminant or on foliage as a commensal and is as a contaminant or on foliage as a commensal and is transmitted via injury from the environment, transmission transmitted via injury from the environment, transmission from animals to humans has not been demonstratedfrom animals to humans has not been demonstrated

lesions occur on extrem ties. They probably begin as lesions occur on extrem ties. They probably begin as injuries or insect bites that do not heal but instead injuries or insect bites that do not heal but instead become indurated, with eventual necrosis and spreading become indurated, with eventual necrosis and spreading ulcerationulceration

single, firm, sometimes itchy, papule that becomes more single, firm, sometimes itchy, papule that becomes more indurated and fluctuant over several weeks and then indurated and fluctuant over several weeks and then breaks down into a spreading, punched-out ulceration breaks down into a spreading, punched-out ulceration with classically undermined edgeswith classically undermined edges

DiagnosisDiagnosis

The burulin skin test The burulin skin test is not is not usefuluseful as a diagnostic tool as a diagnostic tool because early active cases are generally burulin-because early active cases are generally burulin-negativenegative

However, the skin is generally positive in the healing However, the skin is generally positive in the healing stages and following recovery from the active diseasestages and following recovery from the active disease

Histo : coagulation necrosis, septate panniculitis, without Histo : coagulation necrosis, septate panniculitis, without caseation necrosis, but with granulation tissue and giant caseation necrosis, but with granulation tissue and giant cells towards the periphery. Smears and bi-opsy material cells towards the periphery. Smears and bi-opsy material from the necrotic areas from the necrotic areas almost always almost always reveal acid-fast reveal acid-fast bacillibacilli

Laboratory FeaturesLaboratory Features. . Cultures on Cultures on Lowenstein- Jensen medium produce Lowenstein- Jensen medium produce nonpigmented colonies at 32°C to 33°C after nonpigmented colonies at 32°C to 33°C after 6 to 12 weeks, a relatively long incubation 6 to 12 weeks, a relatively long incubation timetime

Prognossis: untreated, ulcerations tend to Prognossis: untreated, ulcerations tend to progress over months to years to involve progress over months to years to involve large areas (Figure 16- 10), sometimes large areas (Figure 16- 10), sometimes involving an entire extremity, be- fore healing involving an entire extremity, be- fore healing with residual scarring, deformity, and with residual scarring, deformity, and lymphedemalymphedema

TreatmentTreatment

Small lesions respond to simple surgical curettage and Small lesions respond to simple surgical curettage and heal by granulationheal by granulation

heat application to 40°C to the involved area has been heat application to 40°C to the involved area has been helpful in some caseshelpful in some cases

mainstay of therapy is surgical excision of the entire mainstay of therapy is surgical excision of the entire area with primary closure or skin graftingarea with primary closure or skin grafting

Drug therapy consisting of dapsone and streptomycin Drug therapy consisting of dapsone and streptomycin with or without ethambutol with or without ethambutol

some response has been seen with trimethoprim-some response has been seen with trimethoprim-sulfamethoxazole fol- lowed by rifampin and minocycline.sulfamethoxazole fol- lowed by rifampin and minocycline.

BALAMUTHIA BALAMUTHIA MANDRILLARISMANDRILLARIS

Balamuthia mandrillaris was first isolated Balamuthia mandrillaris was first isolated from the brain of a mandrill baboon at the San from the brain of a mandrill baboon at the San Diego Wild Animal ParkDiego Wild Animal Park

free-living amebae, at least 3 genera, free-living amebae, at least 3 genera, Naegleria, Acanthamoeba, and Balamuthia, Naegleria, Acanthamoeba, and Balamuthia, are known to cause disease in humans and are known to cause disease in humans and animalsanimals

Only 1 species of Naegleria, N fowleri, causes Only 1 species of Naegleria, N fowleri, causes an acute, fulminant, rapidly fatal infection of an acute, fulminant, rapidly fatal infection of the central nervous system (CNS)the central nervous system (CNS)

primary amebic meningoencephalitis, that primary amebic meningoencephalitis, that predominantly affects healthy young persons exposed predominantly affects healthy young persons exposed to freshwater lakes, ponds, and heated swimming poolsto freshwater lakes, ponds, and heated swimming pools

Amebas splashed or inhaled onto the olfactory epithelium migrate up the olfactory nerve to the brain and spread via the subarachnoid space.

Diagnosis relies on identifying trophozoites by microscopic examination of fresh cerebrospinal fluid specimens or histologic sections of CNS tissue, and on culturing, if necessary.

Clinical manifestationsClinical manifestations

Neurologic signs : hemiparesis, seizures, and aphasia; Neurologic signs : hemiparesis, seizures, and aphasia; altered mental status; head- ache; stiff neck; and cranial altered mental status; head- ache; stiff neck; and cranial nerve palsies, mainly affecting the third and sixth cranial nerve palsies, mainly affecting the third and sixth cranial nerves. Symptoms closely mimic a bacterial or viral nerves. Symptoms closely mimic a bacterial or viral encephalitis, leptomeningitis, or tuberculous meningitis. encephalitis, leptomeningitis, or tuberculous meningitis.

Neuroimaging studies usually reveal multifocal, typically Neuroimaging studies usually reveal multifocal, typically hypodense, contrast-enhancing lesions, often in a hypodense, contrast-enhancing lesions, often in a serpiginous pattern Cerebrospinal findings are generally serpiginous pattern Cerebrospinal findings are generally those of mono- nuclear pleocytosis with an elevated protein those of mono- nuclear pleocytosis with an elevated protein and normal to low glucose.4,11 Gastrointestinal complaints, and normal to low glucose.4,11 Gastrointestinal complaints, such as vomiting, ab- dominal pain, and diarrhea, have also such as vomiting, ab- dominal pain, and diarrhea, have also been reportedbeen reported

many of these patients initially had persistent amebic many of these patients initially had persistent amebic granulomatous lesions in the nasal region. Other reported granulomatous lesions in the nasal region. Other reported sites include the oral cavity, gluteal area, and extremitiessites include the oral cavity, gluteal area, and extremities

Trophozoites measure 15 to 50 m and are characterized by a Trophozoites measure 15 to 50 m and are characterized by a round nucleus with a large spherical, densely staining round nucleus with a large spherical, densely staining nucleolus and abundant cytoplasm containing empty vacuolenucleolus and abundant cytoplasm containing empty vacuole

nucleus might have nucleus might have more than 1 nucleolus, a feature that more than 1 nucleolus, a feature that distinguishes from Acanthamoeba in tissue sectionsdistinguishes from Acanthamoeba in tissue sections

Speciation by indirect immunofluorescence is available for Speciation by indirect immunofluorescence is available for definitive diagnosisdefinitive diagnosis

B mandrillaris grows well at 35 to 37°C on monkey kidney B mandrillaris grows well at 35 to 37°C on monkey kidney cells or human lung fibroblasts, as well as in a complex cells or human lung fibroblasts, as well as in a complex chemical medium containing fetal bovine serumchemical medium containing fetal bovine serum

TreatmentTreatment

no known effective therapy for B mandrillaris infectionno known effective therapy for B mandrillaris infection

The most effective antimicrobial agents tested in vitro The most effective antimicrobial agents tested in vitro are pentamidine and propamidine isethionates, polymyxin are pentamidine and propamidine isethionates, polymyxin B, and gramicidinB, and gramicidin

pentamidinepentamidine is the best choice among anti- microbials is the best choice among anti- microbials tested thus far for amebic meningoencephalitis and tested thus far for amebic meningoencephalitis and cutaneous infection caused by B mandrillariscutaneous infection caused by B mandrillaris

More recently, phenothiazines were discovered to be More recently, phenothiazines were discovered to be effective against B mandrillaris; however, this agent is effective against B mandrillaris; however, this agent is toxic to mammalian cells at high concentrationstoxic to mammalian cells at high concentrations

B mandrillaris, a newly recognized pathogenic B mandrillaris, a newly recognized pathogenic ameba, should be included in the differ- ential ameba, should be included in the differ- ential diagnosis of a granulomatous skin lesion, diagnosis of a granulomatous skin lesion, particularly in the nasal region, in both particularly in the nasal region, in both immunocompetent and immunocom promised immunocompetent and immunocom promised patients.patients.

Earlier diagnosis in our patient might not Earlier diagnosis in our patient might not have altered the outcome, but it would have have altered the outcome, but it would have provided an op portunity to attempt earlier provided an op portunity to attempt earlier treatment with pentamidinetreatment with pentamidine

PentamidinePentamidine

Pentamidine isethionate was approved by the Pentamidine isethionate was approved by the FDA on June 15, 1989, for use in the FDA on June 15, 1989, for use in the treatment of Pneumocystis jiroveci (formerly treatment of Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia (PCP), an Pneumocystis carinii) pneumonia (PCP), an opportunistic infection in people with opportunistic infection in people with HIV/AIDS. Pentamidine is generally used only HIV/AIDS. Pentamidine is generally used only when patients with PCP cannot tolerate the when patients with PCP cannot tolerate the first-line treatment, sulfamethoxazole-first-line treatment, sulfamethoxazole-trimethoprimtrimethoprim

SchistosomiasisSchistosomiasis

Schistosomiasis has been endemic in Egypt at least Schistosomiasis has been endemic in Egypt at least since the time of the ancient Pharaohs, as indicated by since the time of the ancient Pharaohs, as indicated by the presence of calcified ova in the Egyptian mummiesthe presence of calcified ova in the Egyptian mummies

So called bilharzia, is now a widespread endemic dis- So called bilharzia, is now a widespread endemic dis- ease currently found in 75 countriesease currently found in 75 countries

schistosomiasis is a disease affecting agricultural schistosomiasis is a disease affecting agricultural communities, particularly those dependent upon communities, particularly those dependent upon irrigation to support their agricultureirrigation to support their agriculture

especially in areas where the water contains numerous freshwater snails, which may carry the parasite

Schistosoma mansoni and Schistosoma intercalatum cause intestinal schistosomiasis

Schistosoma haematobium causes urinary schistosomiasis

Schistosoma japonicum and Schistosoma mekongi cause Asian intestinal schistosomiasis

Avian schistosomiasis species cause swimmer's itch and clam digger itch

schistosomiasis is a chronic disease. Many infections are subclinically symptomatic, with mild anemia and malnutrition being common in endemic areas. Acute schistosomiasis (Katayama's fever) may occur weeks after the initial infection, especially by S. mansoni and S. japonicum. Manifestations include:

Abdominal pain,Cough,Diarrhea , Eosinophilia — extremely high eosinophil granulocyte (white blood cell) count., Fever, Fatigue, Hepatosplenomegaly

Genital sores — lesions that increase vulnerability to HIV infection. Lesions caused by schistosomiasis may continue to be a problem after control of the schistosomiasis infection itself. Early treatment, especially of children, which is relatively inexpensive, prevents formation of the sores.

Skin symptoms: At the start of infection, mild itching and a papular dermatitis of the feet and other parts after swimming in polluted streams containing cercariae

Occasionally central nervous system lesions occur: cerebral granulomatous disease may be caused by ectopic S. japonicum eggs in the brain, and granulomatous lesions around ectopic eggs in the spinal cord from S. mansoni and S. haematobium infections may result in a transverse myelitis with flaccid paraplegia.

Continuing infection may cause granulomatous reactions and fibrosis in the affected organs, which may result in manifestations that include:

Colonic polyposis with bloody diarrhea (Schistosoma mansoni mostly);

Portal hypertension with hematemesis and splenomegaly (S. mansoni, S. japonicum);

Cystitis and ureteritis (S. haematobium) with hematuria, which can progress to bladder cancer;

Pulmonary hypertension (S. mansoni, S. japonicum, more rarely S. haematobium);

Glomerulonephritis; and central nervous system lesions.

Bladder cancer diagnosis and mortality are generally elevated in affected areas.

Microscopic identification of eggs in stool or urine is the most practical method for diagnosis

Stool examination should be performed when infection with S. mansoni or S. japonicum is suspected, and urine examination should be performed if S. haematobium is suspected. Eggs can be present in the stool in infections with all Schistosoma species

repeated examinations and/or concentration procedures (such as the formalin-ethyl acetate technique)

for field surveys and investigational purposes, the egg output can be quantified by using the Kato-Katz technique (20 to 50 mg of fecal material) or the Ritchie technique.

Eggs can be found in the urine in infections with S. japonicum and with S. intercalatum (recommended time for collection: between noon and 3 PM). Detection will be enhanced by centrifugation and examination of the sediment. Quantification is possible by using filtration through a nucleopore membrane of a standard volume of urine followed by egg counts on the membrane.

Investigation of S. haematobium should also include a pelvic x-ray as bladder wall calcificaition is highly characteristic of chronic infection

Tissue biopsy (rectal biopsy for all species and biopsy of the bladder for S. haematobium) may demonstrate eggs when stool or urine examinations are negative

The eggs of S. haematobium are ellipsoidal with a terminal spine, S. mansoni eggs are also ellipsoidal but with a lateral spine, S. japonicum eggs are spheroidal with a small knob

Eggs of Eggs of S. haematobium S. haematobium in wet mounts in wet mounts of urine concentrates, showing the of urine concentrates, showing the

characteristic terminal spinecharacteristic terminal spine

TreatmentTreatment

All individuals with schistosomiasis should receive treatment even All individuals with schistosomiasis should receive treatment even if they are symptom-free.if they are symptom-free.

Praziquantel 40mg/kg/d for 3 days gives 95% cure rate with no Praziquantel 40mg/kg/d for 3 days gives 95% cure rate with no relapses Treatment before significant damage or severe relapses Treatment before significant damage or severe complications usually produces good resultscomplications usually produces good results

Severe Severe Katayama fever* Katayama fever* may require treatment with systemic may require treatment with systemic corticosteroids to manage the acute hypersensitivity reaction. corticosteroids to manage the acute hypersensitivity reaction. Praziquantel is less effective for Katayama fever and can worsen Praziquantel is less effective for Katayama fever and can worsen symptoms due to antigen release. It may be useful to either delay symptoms due to antigen release. It may be useful to either delay treatment with praziquantel therapy or co-administer with treatment with praziquantel therapy or co-administer with corticosteroids and give a second course of praziquantel after 3-6 corticosteroids and give a second course of praziquantel after 3-6 monthsmonths

*(Katayama fever*(Katayama fever  fever associated with severe schistosomal   fever associated with severe schistosomal infections, accompanied by hepatosplenomegaly and by infections, accompanied by hepatosplenomegaly and by eosinophilia)eosinophilia)

Prevention of schistosomiasisPrevention of schistosomiasis

There is no vaccine currently available for There is no vaccine currently available for schistosomiasis.schistosomiasis.

Travellers should avoid exposure to freshwater in Travellers should avoid exposure to freshwater in endemic areas – avoid bathing in ponds and lakes.endemic areas – avoid bathing in ponds and lakes.

Bath water should be heated for 5 minutes at 65°C. Bath water should be heated for 5 minutes at 65°C. Water held in a storage tank for at least 48 hours Water held in a storage tank for at least 48 hours should be safe for showering.should be safe for showering.

Drink bottled water, or water that has been boiled Drink bottled water, or water that has been boiled for at least one minute.for at least one minute.

RELATIONSHIP BETWEEN SCHISTOSOMIASIS RELATIONSHIP BETWEEN SCHISTOSOMIASIS AND BLADDER CANCERAND BLADDER CANCER

association of bladder cancer with schistosomiasis association of bladder cancer with schistosomiasis seems to be related to the endemicity of the parasite seems to be related to the endemicity of the parasite

The consensus of available information strongly The consensus of available information strongly implicates an association between S. haematobium implicates an association between S. haematobium infection and the induction of bladder cancerinfection and the induction of bladder cancer

It was estimated that of 11,626 cancer cases of all It was estimated that of 11,626 cancer cases of all types recorded at the Cairo Cancer Institute from 1970 types recorded at the Cairo Cancer Institute from 1970 to 1974, 27.6% were bladder cancer cases associated to 1974, 27.6% were bladder cancer cases associated with schistosomiasis, and that of 2,500 new cancer with schistosomiasis, and that of 2,500 new cancer patients at the Cairo Cancer Institute every year, 27% patients at the Cairo Cancer Institute every year, 27% had cancer of the bladder associated with had cancer of the bladder associated with schistosomiasis schistosomiasis

initiation, activated macrophages induced at the sites of initiation, activated macrophages induced at the sites of inflammation are implicated in the generation of inflammation are implicated in the generation of carcinogenic NNA and reactive oxygen radicals that lead to carcinogenic NNA and reactive oxygen radicals that lead to DNA damage and subsequently to events such as mutationsDNA damage and subsequently to events such as mutations

increased levels of the enzymes responsible for the increased levels of the enzymes responsible for the activation of carcinogenic N-nitroso compounds, aromatic activation of carcinogenic N-nitroso compounds, aromatic amines, and polycyclic aro- matic hydrocarbons have been amines, and polycyclic aro- matic hydrocarbons have been foundfound

Physical damage to the urothelium and mucosa caused by Physical damage to the urothelium and mucosa caused by the activities of the worms leads to restorative hyperplasiathe activities of the worms leads to restorative hyperplasia promoting stimulus to propagate cells in which the sequence promoting stimulus to propagate cells in which the sequence of genotoxic (DNA- damaging) events leading to the initiation of genotoxic (DNA- damaging) events leading to the initiation of the premalignant change is completeof the premalignant change is complete

recognizing this sequence of events, it is fairly recognizing this sequence of events, it is fairly clear how prevention could be achieved clear how prevention could be achieved

Elimination of the parasite through Elimination of the parasite through education, improved hygiene, and improved education, improved hygiene, and improved conditions for living and working are the conditions for living and working are the obvious solutions, but the level of investment obvious solutions, but the level of investment required for this is well beyond the resources required for this is well beyond the resources of most of the countries where infection is of most of the countries where infection is endemic. A possible interim solution that endemic. A possible interim solution that requires less extensive financial resources is requires less extensive financial resources is chemotherapy with effective agents such as chemotherapy with effective agents such as prazi- quantelprazi- quantel

Prevention and Prevention and controlcontrol

Short term measureShort term measureChlorination of waterChlorination of water

safe drinking water is the most important preventive measure to be safe drinking water is the most important preventive measure to be implemented following flooding, in order to reduce the risk of outbreaks implemented following flooding, in order to reduce the risk of outbreaks of water-borne diseases.of water-borne diseases.

Free chlorine is the most widely and easily used, and the most affordable Free chlorine is the most widely and easily used, and the most affordable of the drinkingof the drinking

water disinfectants. : effective against nearly all waterborne pathogens water disinfectants. : effective against nearly all waterborne pathogens ((except Cryptosporidium parvum oocysts and Mycobacteria speciesexcept Cryptosporidium parvum oocysts and Mycobacteria species). ).

doses of a few mg/litre and contact times of about 30 minutes, free doses of a few mg/litre and contact times of about 30 minutes, free chlorine generally inactivates >99.99% of enteric bacteria and viruses.chlorine generally inactivates >99.99% of enteric bacteria and viruses.

household water treatment, the most practical forms of free chlorine are household water treatment, the most practical forms of free chlorine are liquid sodium hypochlorite, solid calcium hypochlorite and bleaching liquid sodium hypochlorite, solid calcium hypochlorite and bleaching powder (chloride of lime; a mixture of calcium hydroxide, calcium powder (chloride of lime; a mixture of calcium hydroxide, calcium chloride and calcium hypochlorite).chloride and calcium hypochlorite).

. After 30 minutes, the residual concentration of active chlorine in the . After 30 minutes, the residual concentration of active chlorine in the water should be between 0.2–0.5 mg/l, which can be determined using a water should be between 0.2–0.5 mg/l, which can be determined using a special test kit.special test kit.

Vaccination against hepatitis Vaccination against hepatitis A:A:

The use of hepatitis A vaccines for mass The use of hepatitis A vaccines for mass immunization is not recommended.immunization is not recommended.

Vaccination of high-risk groups, such as persons Vaccination of high-risk groups, such as persons involved in the management of drinking water, involved in the management of drinking water, waste water or sewage might be considered. waste water or sewage might be considered.

In case of an outbreak of hepatitis A consider In case of an outbreak of hepatitis A consider immunization of contacts. The use immunization of contacts. The use ofimmunoglobulins is not recommended. ofimmunoglobulins is not recommended.

Diagnosis of acute hepatitis A is confirmed by anti-Diagnosis of acute hepatitis A is confirmed by anti-HAV IgM antibodies.HAV IgM antibodies.

Malaria prevention:Malaria prevention:

flooding flooding does not necessarily lead to an immediate major does not necessarily lead to an immediate major increase in mosquito numbersincrease in mosquito numbers, and there may still be time to , and there may still be time to implement preventive measures such as indoor residual implement preventive measures such as indoor residual spraying, or the retreatment/distribution of ITNs in areas spraying, or the retreatment/distribution of ITNs in areas where their use is well-known. This will also have an effect where their use is well-known. This will also have an effect on other mosquito-borne diseases.on other mosquito-borne diseases.

Early detection: it is important to track weekly case numbers Early detection: it is important to track weekly case numbers and provide laboratory-based diagnosis (perhaps only for a and provide laboratory-based diagnosis (perhaps only for a % of fever cases to track the slide/test positivity rate), to % of fever cases to track the slide/test positivity rate), to pick up the early stages of a malaria epidemicpick up the early stages of a malaria epidemic

Free medical care: with Free medical care: with artemisinin-based combination artemisinin-based combination therapy therapy should be provided when should be provided when a falciparum malaria a falciparum malaria epidemic is confirmedepidemic is confirmed, and an active search for fever cases , and an active search for fever cases may be necessary to reduce mortality in remote areas with may be necessary to reduce mortality in remote areas with reduced access to health care services.reduced access to health care services.

HealthHealth EducationEducation

Promote good hygienic practice.. Promote good hygienic practice..

•• Ensure safe food preparation techniques.Ensure safe food preparation techniques.

•• Ensure boiling or chlorination of water.Ensure boiling or chlorination of water.

•• Vital importance of early diagnosis and Vital importance of early diagnosis and treatment for malaria (within 24 hours of treatment for malaria (within 24 hours of onset ofonset of fever)fever)

Handling corpsesHandling corpses

Burial is preferable to cremation in mass causalities and where Burial is preferable to cremation in mass causalities and where identification of victims is not possible.identification of victims is not possible.

false belief false belief that they represent an epidemic hazard if not buried or that they represent an epidemic hazard if not buried or burned immediately.burned immediately.

Bodies should not be disposed of unceremoniously in mass graves and Bodies should not be disposed of unceremoniously in mass graves and this does not constitute a public health a public health measure, violates this does not constitute a public health a public health measure, violates important social norms and can waste scarce resources.important social norms and can waste scarce resources.

Families should have the opportunity to conduct culturally appropriate Families should have the opportunity to conduct culturally appropriate funerals and burials according to social custom.funerals and burials according to social custom.

Where customs vary, separate areas should be available for each social Where customs vary, separate areas should be available for each social group to exercise their own traditions with dignity.group to exercise their own traditions with dignity.

Where existing facilities such as graveyards or crematoria are Where existing facilities such as graveyards or crematoria are inadequate, alternative locations or facilities should be provided.inadequate, alternative locations or facilities should be provided.

The affected community should also have access to materials to meet The affected community should also have access to materials to meet the needs for culturally acceptable funeral pyres and other funeral rites.the needs for culturally acceptable funeral pyres and other funeral rites.

For For workers that workers that routinely handle routinely handle

corpsescorpses Graveyards should be at least 30m from groundwater sources used for drinking Graveyards should be at least 30m from groundwater sources used for drinking water water

The bottom of any grave must be at least 1.5m above the water table with a 0.7mThe bottom of any grave must be at least 1.5m above the water table with a 0.7m unsaturated zoneunsaturated zone

Surface water from graveyards must not enter inhabited areasSurface water from graveyards must not enter inhabited areas

Ensure universal precautions for blood and body fluids Ensure universal precautions for blood and body fluids

Ensure use and correct disposal of gloves (no re-use) Ensure use and correct disposal of gloves (no re-use)

Ensure use of body bags Ensure use of body bags

Ensure hand-washing with soap after handling bodies and before eating Ensure hand-washing with soap after handling bodies and before eating

Ensure disinfection of vehicles and equipment Ensure disinfection of vehicles and equipment

Bodies do not need to be disinfected before disposal (except in case of cholera) •Bodies do not need to be disinfected before disposal (except in case of cholera) •

Vaccinate workers against hepatitis BVaccinate workers against hepatitis B

Long term measuresLong term measures

Legislative/administrative issues:Legislative/administrative issues:

Create Disaster-Preparedness Programmes Create Disaster-Preparedness Programmes and Early Warning Systemsand Early Warning Systems. .

Improve surveillance on a local, national, Improve surveillance on a local, national, international and global level.international and global level.

Promote tap-water quality regulation and Promote tap-water quality regulation and monitoring.monitoring.

Enforce high standards of hygiene.Enforce high standards of hygiene.

Technical issues:Technical issues:

Improve water treatment and sanitation.Improve water treatment and sanitation.

Keep infectious disease control programmes Keep infectious disease control programmes active and efficientactive and efficient