In London still

the London School of Hygiene & Tropical Medicine

 

the London School of Hygiene & Tropical Medicine

 

No, not a reference to lyrics from the Waifs. More a matter of ruminating over the consequences of a flying visit to the UK capital; home of the London School of Hygiene and Tropical Medicine. The London School is the larger of the two remaining British centres of tropical medicine and maintains R & D collaborations with partner centres round the world; a truly international centre in more ways than one. The MicroGnome was there to plan yet more field research and deliver a lunch-time talk on the field applications of molecular microbiology [Field Apps LSTM 2010], and was rewarded with a day-long feast of medical microbiology with fellow micrognauts.

Also on the London itinerary was the map reading room at the Royal Geographical Society‘s Kensington Gore site. Think modern university library but switch maps for books. Heaven must have a map room. Micrognome was on a quest for early depictions of tropical Western Australia. He was rewarded by maps from the original John Forrest expedition to the Kimberley and Canning’s survey for the eponymous stock route,. It is so easy to view physical geography through Google Earth or with the aid of a GPS receiver; data which becomes obsolete every times the geosatellite passes by. Not for us the sheer hard, footslogging of travelling survey teams. Which makes the hand drawn survey maps all the more impressive. This may only be the surface with marginal notes on the topography and its flora. But these early geographical surveys are records of systematic exploration, and an expanding state economy. They provide us with time, date and location markers for the start of movements of livestock and other traffic which may have contributed to the distribution of zoonotic and environmental diseases. 

London is a complex city with many faces, and much to occupy the traveller beyond the headline tourist attractions. It brings to mind the sort of list you can probably find somewhere on the Net: 

you know you’re in London when:

  • you recognise those old buildings from the label on a sauce bottle
  • you hear a clock chime the hour and think it’s the lead in to the news
  • the skyline has appeared in the Bill, Spooks and countless other series shown on the ABC
  • they warn you to ‘Mind the Gap’ even when it’s only a couple of centimetres
  • you can find your way round underground better than you can on top
  • there’s a coffee shop, sandwich chain and old world pub on every street
  • and the suburbs have names that must have been introduced by early Australian settlers

Fever, diarrhoea & international travel

Gangrenous toes

Clinical Case of the Febrile Returned Traveller

Ms A, a 23 year old aid worker who has just returned after half a year overseas. She spent six months on aid work in the Amazon region and had a two week holiday in Mozambique on her way home. She took no travel health precautions before or during her travel.

She developed fever and profuse diarrhoea on her last day in Mozambique, and went straight from the airport to the Emergency Department.

On initial examination she was alert and oriented, but unwell and dehydrated with a pulse of 120 and a blood pressure of 90/60. She had diffuse abdominal tenderness and a mildly enlarged spleen. Her chest was clear.

Q1. What is your differential diagnosis?

  • infectious enterocolitis: ETEC, Salmonella, Campylobacter, Shigella.
  • malaria
  • dengue
  • typhoid
  • pelvic inflammatory disease
  • appendicitis

The initial investigations were:

  • Hb  100
  • WCC  8.6
  • Plts  25
  • Na  135
  • K  4.8
  • Ur  13.7
  • Cr 149
  • Stool microscopy – no parasites seen

These blood investigations produced this result.

Q2. What are these investigations ?

Thick film to detect malaria parasites (Plasmodium species), and thin film to identify which species

Q3. What is the result?

Plasmodium falciparum, high level parasitaemia

Q4. What other widely available investigation would give a rapid confirmatory result?

Rapid HRP-2 card test for Plasmodium falciparum

Q5. What treatment would you commence?

  1. basic resuscitation comes first
  2. then intravenous antimalarial agent, preferably artesunate

The patient had a very stormy course.

  • she was given 8L iv crystalloid in the first 24h, iv artesunate (SAS Category A, requiring informed consent), and exchange transfusion (6 units packed cells)
  • despite this, she deteriorated and went into multiple organ systems failure and DIC, requiring 29 days in intensive care
  • she was discharged from hospital, having lost 8/10 toes to necrosis

Additional resources

Military epidemiology

The Kimberley Front

Make no mistake about it: our battle is with the germs. The front line is particularly volatile and liable to change in the immediate future. Here is an approximate view of the forces of infection ranged against us, subject to change on the arrival of more up to date disease intelligence.

The symbol conventions used follow the principles of campaign maps. You can see how thinly dispersed health units are in the northwest, compared to the disposition of immediate disease threats.

Those threats include arbovirus infections and neglected bacterial diseases, which you can follow on the Priobe Net and Life in the Fast Lane. Whitmore’s bacillus is particularly notable for its ability to lay low for many months and resurface when the conditions are right, to produce severe illness or less acute infection in pockets of disease activity throughout the Kimberley.  Leazar’s personal infection is unknown in this region, but other flavi-, alpha- and assorted other arboviruses are a potential mosquito-borne threat. The build-up of an unprotected civilian population in this region presents a possible vulnerability to the endemic infections of the area. Forewarned is forearmed.

Ena Sharples on tropical medicine

Ena S

What’s the connection between Ena Sharples; the hairnet helmeted doyenne of Coronation St and tropical medicine? Coronation St afficionados would be hard pressed to place the sullen rows of back-to-back brick terraces with the humid tropics.

The explanation will be unveiled during next Tuesday’s tropical medicine breakfast in the Emergency Department seminar room at Sir Charles Gairdner Hospital.

You may glean a shrew idea if you take a look at the lecture notes before Tuesday.

Download (PDF, 830.79KB)

Tropical Medicine: next instalment

For those following the FACTM pt 1 series, the next instalment is just around the corner, if you’re planning your diary for next week. The face-to-face session will take place at the later time of  7:30am next Tuesday (25th May) in the ED seminar room at Sir Charles Gairdner Hospital, and will run for an hour in its usual two topic format.

Next week’s session is open to junior medical staff and there will be a light breakfast as usual. The MicroGnome apologises for not having the unit notes ready in time for this post, owing to an encounter with arboviruses in Queensland earlier this week. He assures you that the lecture material will meet the usual standard, and was inspired by recent fieldwork in tropical Australia.

Tuesday’s units will cover Leptospirosis, Melioidosis and Scrub Typhus; three infections prevalent in the Australian tropics. Reading for this unit includes: