A review of stool ova and parasite examination in the tropics.
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Adult↗
Biomedical subjects
N J Beeching
Publications and source records attributed to N J Beeching.
Helminth infections in British troops following an operation in Sierra Leone.
One hundred and fifty-three British soldiers and 86 Royal Air Force (RAF) personnel were deployed on a hostage rescue operation in Sierra Leone. For 3 days they were exposed to various infection risks and 6 weeks later some of the soldiers presented with gastrointestinal complaints. Both groups were screened with structured questionnaires, blood investigations and (where indicated) faecal microscopy and charcoal culture for helminths. Definite and probable cases of helminth infection were treated with albendazole and all soldiers were screened again after 3 months. Among the soldiers investigated, 73/145 (50%) reported gastrointestinal symptoms and 70/139 (50%) had eosinophilia. Among these, 17/66 (26%) had hookworm infection, 6/66 (9%) had Strongyloides stercoralis infection and 1/66 (2%) had Giardia lamblia infection. Eosinophilia was most strongly associated with entering the enemy camp and being in the platoon that attacked the area around the camp latrines. Among RAF personnel, who were not involved in activities on the ground, 3/86 (3%) had borderline eosinophilia. Treatment of 105/153 (69%) soldiers with albendazole was well tolerated and, on follow-up screening 3 months later, 23/124 soldiers (19%) had gastrointestinal symptoms and 18/121 (15%) had eosinophilia. Faecal investigations and schistosomiasis serology tests were all negative at this stage.
Albendazole↗
Clinical and diagnostic findings of an echovirus meningitis outbreak in the north west of England.
INTRODUCTION: An outbreak of echovirus meningitis occurred in the north west of England in 2001. This paper reviewed the clinical features and the role of different diagnostic methods. METHODS: This was a prospective study of adults admitted to a regional infectious disease unit with a probable diagnosis of meningitis, March to August 2001. RESULTS: Half the 40 cases were male; median age was 28 (range 16-51) years. Fifteen of 38 (39.5%) were smokers, and 20 of 24 (83.3%) had close contact with children. Median (range) duration of symptoms was 1.1 (0.25-7) days. Symptoms included headache (100%), photophobia (87.5%), and nausea (67.5%), and severity ranged from minimal signs to those consistent with a meningoencephalitis. The diagnosis was confirmed virologically in 29 of 40 (72%); echovirus 30 was isolated from six. Cerebrospinal fluid (CSF) enterovirus polymerase chain reaction (PCR) was positive in 26 of 32 (81%), and CSF virus culture in 3 of 16 (19%). Thirty one per cent of CSF samples had a neutrophil predominance, and 3 of 29 (10%) virologically confirmed cases had normal CSF microscopy and biochemistry. CONCLUSION: CSF microscopy may be normal or suggest bacterial meningitis in a substantial minority of cases of echovirus meningitis. CSF PCR for enterovirus seems to be more sensitive than virus culture of CSF, although PCR does not yield information on circulating virus type. Early and accurate diagnosis could reduce both use of parenteral antibiotics and length of hospital stay with both morbidity and cost implications. Close contact with children may be a risk factor, particularly if good hygiene measures are not practised.
Adolescent↗
Increase in hospital mortality from non-communicable disease and HIV-related conditions in Bulawayo, Zimbabwe, between 1992 and 2000.
The HIV/AIDS pandemic is creating a strain on health care services in the developing world, with knock-on consequences for HIV negative patients. We looked for possible changes over time in the patterns of illness and outcomes of admission to an adult medical unit in Zimbabwe. We performed a prospective descriptive study of discharge diagnoses and causes of in-hospital ;mortality for all medical patients under the care of one consultant at Mpilo Central Hospital, Bulawayo, Zimbabwe. Two similar 7-month periods were compared in 1992 and 2000. Data recorded included: initials, sex, alive or dead status, diagnosis and HIV/AIDS status. Similar numbers of patients were admitted in 1992 and 2000 (1305 and 1369), but in-hospital mortality increased from 13.3% to 28.6% (P < 0.001), especially in male patients (13.1% to 33.9% P < 0.001). Mortality rates increased for both infectious and non-communicable diseases such as cardiac failure, stroke and diabetes. The 10 most common diagnoses were similar, apart from Pneumocystis carinii pneumonia (PCP) cases, which increased from 18 to 90. The proportion of patients clinically or serologically positive for HIV/AIDS rose from 13.9% to 51.1% (P < 0.001), but the number of cases of the HIV wasting syndrome (SLIM)/chronic gastroenteritis did not change significantly. In 1992 there happened to be a large number of cases of malaria transmission. Mortality related to both communicable and non-communicable diseases increased, confirming that HIV negative patients are also being affected by the strain on health services. Although based on clinical and radiological diagnosis, PCP pneumonia appears to be increasingly common in this area.
AIDS-Related Opportunistic Infections↗
Leprosy in Britain: 50 years experience in Liverpool.
BACKGROUND: Leprosy is a chronic infection that presents with varying dermal and neurological symptoms, and which can lead to extensive disability and morbidity, often with accompanying social stigma. AIM: To review the patients presenting to the Liverpool School of Tropical Medicine (LSTM) between 1946 and 2003, looking specifically at country of birth and of infection, details of clinical presentation, diagnosis, management and reactions. DESIGN: Retrospective record review. METHODS: We retrieved all available clinical records for patients seen between 1946 and 2003 (n = 50), consisting of letters, hospital and LSTM casenotes, and some radiographs and photographs. Any history of tuberculosis or diabetes was recorded. RESULTS: Most patients (64%) were born in the Indian subcontinent, and most were thought to have contracted the disease there (62%). Features at presentation included anaesthetic skin lesions in 19 (36%), hypopigmentation in 15 (30%), and peripheral nerve enlargement in 25 (50%). Diagnoses were made by a combination of clinical data and biopsy (60%), and slit skin smears were positive for acid-fast bacilli in 61% of multibacillary patients. Initial presentation was with a leprosy reaction in five cases (10%), and reactions were documented in 42% of all patients. Treatments were varied, progressing from traditional Eastern medicine to the WHO-approved multidrug therapy in use today, with prophylaxis for children and close contacts. DISCUSSION: Leprosy remains an important diagnosis to consider in patients with a history of work or travel in the tropics, and is a diagnosis with far-reaching medical, social and emotional consequences.
Adolescent↗
Lower-limb deep-vein thrombosis in a general hospital: risk factors, outcomes and the contribution of intravenous drug use.
BACKGROUND: Much of the morbidity associated with deep-vein thrombosis (DVT) is absent from the evidence base used to define best clinical practice. Intravenous (IV) drug use is an increasingly frequent cause of DVT. AIM: To obtain a profile of DVT patients in routine clinical care, and determine the contribution of IV drug use. DESIGN: Retrospective case-note review. METHODS: We reviewed 232 episodes of lower-limb DVT in a large district general hospital during 1996. RESULTS: Patients had mean (range) age 62.8 (21-97) years, with 43.9% aged > 70 years. A large proportion would have been excluded from prospective studies that have contributed to current DVT guidelines. Risk factors included smoking (33.0%), immobility (26.5%), previous DVT (23.6%), surgery in the last 3 months (18.2%), malignancy (16.5%), varicose veins (10.5%) and IV drug use (6.9%). Forty-five (19.4%) had multiple risk factors. Postsurgical DVT commonly presented from the community following initial hospital discharge. Intravenous drug use accounted for 48.4% of episodes in patients aged < or =40 years. Thrombosis was right-sided in 68.8% of IV drug users, compared to 38.2% in others (p = 0.034). DISCUSSION: Our patients differed from those in most of the prospective studies used to develop routine clinical care pathways for DVT. Intravenous drug use is an important cause of community-acquired DVT in young adults.
Adult↗
'Disappearing diabetes'--resolution of apparent Type 1 diabetes in a patient with AIDS and cytomegalovirus (CMV) infection.
A 30-year-old African female with established acquired immunodeficiency syndrome (AIDS) and no history of diabetes, presented in severe diabetic ketoacidosis (DKA). Blood pH was 6.96, serum bicarbonate 5 mmol/l, plasma glucose (PG) 33.0 mmol/l, and urine heavily positive for ketones. She responded to standard treatment and was established on twice-daily subcutaneous insulin. Four months later her insulin was stopped because of hypoglycaemic attacks on small doses. A glucose tolerance test (GTT) at 6 months postdiagnosis was normal (fasting PG 4.4 mmol/l and 2 h PG 7.5 mmol/l), and at 12 months random PG was 4.1 mmol/l and HbA1c 4.3%. The onset of her apparent Type 1 diabetes coincided with an HIV-associated cytomegalovirus (CMV) infection, and a reversible 'CMV insulitis' may be an explanation. Alternatively, the patient may have had what has recently been described as 'atypical diabetes' in African or Afro-Caribbean diabetic patients. Here resolution of diabetes may occur after presentation, though complete return to normoglycaemia after true DKA is very unusual.
AIDS-Related Opportunistic Infections↗
Clinical guidelines for the management of cutaneous leishmaniasis in British military personnel.
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Animals↗
Elevated mortality following diagnosis with a treatable disease: tuberculosis.
OBJECTIVE: To determine whether previous diagnosis with tuberculosis (TB) increases the risk of mortality. DESIGN: A retrospective survey of 439 TB patients in the city of Liverpool, population 439500, over an 8-year period. OUTCOMES: Mortality compared with the general population; cause of death as identified from death certificates. RESULTS: A total of 104 (23.7%) TB cases had died within the follow-up period. For 45-54 year olds, the standardised mortality ratio (SMR) was 1101, an 11-fold higher mortality than expected from the Liverpool population. The SMR then declined with age, but remained higher in males than in females. Death certificates showed that 34 (30.8%) died from TB and 26 (21%) from bronchopneumonia. Malignancy was the cause of death in 24 cases (28%), including 16 with lung tumours, all in patients aged under 75 years. This gave a 30-fold greater mortality from lung cancer compared with the general population aged under 75. CONCLUSIONS: TB increases the risk of mortality compared with the general population, with unexpectedly high mortality from lung cancer in cases aged under 75. Older patients die from TB itself or other chest diseases. Common risk factors for the Liverpool population probably contribute to elevated mortality from all chest-related diseases, including TB.
Adolescent↗
Trachipleistophora hominis infection in the myocardium and skeletal muscle of a patient with AIDS.
OBJECTIVES: To review the literature relevant to microsporidial infection of muscle and to describe a case of human microsporidial infection involving both skeletal and cardiac muscle. METHODS: Samples from an AIDS patient with myositis have been examined by light and electron microscopy. RESULTS: We describe the findings at autopsy of a 47 year old Australian male with late stage AIDS, who had skeletal and cardiac muscle involvement with the microsporidian Trachipleistophora hominis. This is the third definitively identified case of human T. hominis infection and the first to describe infection of the myocardium. CONCLUSIONS: Microsporidial infection of muscle is rare in humans, but more work is needed to elucidate both the organisms and routes of transmission of this group of parasitic protozoa.
AIDS-Related Opportunistic Infections↗
A British Second World War veteran with disseminated strongyloidiasis.
A case is described of a 78-year-old British veteran of the Second World War (1939-45) who was stationed in Southeast Asia and who developed a recurrent pneumonia with blood eosinophilia. He was treated with steroids, and eventually died with a severe Pseudomonas pneumonia. Just prior to death, larvae of Strongyloides stercoralis were identified in his sputum, and a specific serum ELISA test was later positive. At autopsy no other organs were involved, but bronchoalveolar carcinoma was found. Longstanding (57 years) chronic strongyloidiasis in a veteran who served in Southeast Asia but who was not a prisoner of war is very unusual. The pattern of dissemination was also not that of a true hyperinfection syndrome, and the case demonstrates the continued need for diagnostic vigilance amongst former soldiers who were based in the Far East.
Aged↗
Burden and cost of imported infections admitted to infectious diseases units in England and Wales in 1998 and 1999.
BACKGROUND: International travel from the UK has been rising, and the number of imported infections has increased. This study aimed to describe the number, nature, origin, clinical burden and cost of imported infections treated in infectious disease units (IDU) in England and Wales. METHOD: Information about all admissions in 1998 and 1999 with illnesses considered to have been acquired during their most recent travel abroad was collected retrospectively by IDUs using a pre-piloted questionnaire. RESULTS AND ANALYSIS: Four of the 23 IDUs in England and Wales were able to complete the questionnaires. They reported a total of 421 travel related admissions during the 2-year period. Three hundred and ninety-two of these cases were attributed to infectious causes, and of these a discharge diagnosis was made for 340 cases. The total number of bed days used to treat cases of imported infection was 2918. The most common diagnosis was malaria. The odds ratio that cases of imported infection were malaria was highest following visits to Africa. The average cost per bed day on the IDUs was around pound sterling 100, and on this basis, the total cost of treating imported infections on the four IDUs in 2 years was around pound sterling 289,000. The relative risk of acquiring an imported infection requiring treatment on an IDU was greatest for travellers to Africa. CONCLUSIONS: From this study, the estimate of the total annual cost of IDU treatment for imported infections in England and Wales is in excess of pound sterling 800,000. Many cases may be preventable with prophylactic medication and vaccination and travel advice on risk reduction. Further information about imported infections would be useful to inform travel medicine services, other clinicians and travellers about the health risks associated with travel to specific areas, and help to target and assess the cost effectiveness of preventative measures.
Adult↗
Chronic Strongyloides stercoralis infection in former British Far East prisoners of war.
BACKGROUND: Chronic infections with the nematode worm Strongyloides stercoralis can occur in former WWII Far East prisoners of war (FEPOWs). The condition may be asymptomatic, but frequently causes a characteristic urticarial 'larva currens' rash. Under conditions of immunosuppression (particularly systemic corticosteroid treatment) potentially fatal dissemination of larvae ('hyperinfection') may occur. AIM: To review our total experience of strongyloidiasis in former FEPOWs, and investigate its prevalence, characteristics and risk factors. DESIGN: Retrospective case series. METHODS: We reviewed 2072 records of all FEPOWs seen at the Liverpool School of Tropical Medicine, 1968-2002. Cases with strongyloidiasis were compared with non-infected controls. RESULTS: There were 248 (12%) with strongyloidiasis. Diagnostic features included larva currens rash (70%), eosinophilia (66%), positive faecal culture (30%), positive faecal microscopy (26%), and positive serology (64%). Mean (+/-SD) age of cases was 65 +/- 7 years, and as expected, their blood eosinophil counts were significantly higher than controls (775 vs. 238 x 10(6)/l, p < 0.001). Captivity on the Thai-Burma Railway (vs. elsewhere) was significantly associated with strongyloidiasis (78% cases vs. 40% controls, OR 4.19, CI 2.70-6.81, p < 0.001). In terms of prevalence, strongyloidiasis occurred in 166/1032 men imprisoned on the Burma Railway (16.1%). Malaria (88% vs. 69%, p < 0.001) and tropical ulcer (53% vs. 42%, p < 0.02) were more common amongst cases than controls, probably because these diseases were very common on the Burma Railway. DISCUSSION: S. stercoralis infection is common amongst ex-FEPOWs, particularly those from the Thai-Burma Railway project. It is usually characterized by a 'larva currens' rash and marked eosinophilia. The condition is eminently treatable, and continued diagnostic surveillance is needed, if cases of potentially fatal hyperinfection are to be avoided.
Aged↗
The stool examination reports amoeba cysts: should you treat in the face of over diagnosis and lack of specificity of light microscopy?
Amoebiasis is a common clinical diagnosis in tropical settings and clinicians continue to treat asymptomatic carriers diagnosed by light microscopy. A minority of carriers, however, are infected with Entamoeba histolytica and the remaining with the non-pathogenic Entamoeba dispar. We compared the diagnostic results of 298 asymptomatic residents of Aracaju, Brazil, obtained by different diagnostic methods, and ascertained their clinical symptoms, to highlight the implications for practitioners. Fifty-eight (19.4%) specimens were amoebae positive by microscopy. Of these, 38 (13%) were E. histolytica/E. dispar enzyme-linked immunosorbent assay (ELISA) positive and 4 (1%) E. histolytica ELISA positive. The frequent use of anti-amoebic treatment on the basis of non-specific symptoms and the findings of light microscopy tests is not justified. Methods for the specific diagnosis of E. histolytica infection for developing countries are urgently needed.
Adolescent↗
Tuberculous osteomyelitis: chasing the elusive tubercle.
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Adult↗
Adrenoleukodystrophy: a trap for the physician.
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Adrenoleukodystrophy↗
Implementation of new BTS guidelines in acute medical assessment units.
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Anti-Infective Agents↗
Detection of Cryptosporidium amongst diarrhoeic and asymptomatic children in Jeddah, Saudi Arabia.
Between the March and May of 2000, stool specimens were collected from children aged <5 in six pre-school crèches and clinics in the Jeddah area of Saudi Arabia. Sixty-three (25%) of the children had diarrhoeal disease but the other 190 were asymptomatic. When the stool samples were stained and examined for the oocysts of Cryptosporidium spp. and other enteric protozoa, 20 (32%) of the symptomatic children but only nine (4.7%) of the asymptomatic were found to be excreting Cryptosporidium oocysts. Similarly, Cyclospora cayetanensis was found, always as a co-infection with Cryptosporidium sp., in seven (11%) of the children with diarrhoeal disease but only eight (4.2%) of the asymptomatics. One asymptomatic child was found to be co-infected with Isospora belli and Cryptosporidium. Giardia intestinalis and cysts of Entamoeba histolytica/dispar were detected in 18 (29%) and nine (14%) of the children with diarrhoeal disease and in eight (4.2%) and 13 (6.8%) of the asymptomatic children, respectively. This appears to be the first report of Cy. cayetanensis from Saudi Arabia and the highest prevalence of Cryptosporidium infection ever described.
Animals↗