47 Clinical Cases

David Maeby 25/09/18

47.1 Case One: Measles

  • Fever, runny nose, and sore eyes for 3 days

  • Temp 38

  • BCG vaccine, DTP (not fully immunised)
  • No unwell contacts
  • Not been eating and drinking
  • Mother is well

  • hasn’t had any other treatment

47.1.1 Examination:

  • Koplik Spots
  • Conjunctivitis
  • Look at cornea

There’ll be a desquamating rash

47.1.2 Investigations:

  • Malaria
  • Point of care HIV
  • CXR: Pneumonia is a complication of measles

Measles cause immunosuppresion:

  • Secondary pneumonia
  • Malnutrition/malabsorption

  • Herpes Simplex Keratitis on Cornea - so in poor vaccination setting measles is a important cauase of blindness

  • Marasmic Kwashiorkor - Look up. Wasting, oedema, skin tearing from this

Kwashiorkor - Gaa language - “The disease of the baby who is displaced from the breast”. As it used to happen in weaning.

  • Cancrum Oris/Noma - not specifically caused by measles, is caused by malnutrition - Necrotic gingivitis affecting the gums, caused by anaerobes. If caught early can be treated with anaerobes

47.1.3 Management:

Vitamin A ? One paper about it’s use in measles. Mortality and time to hospital discharge lower in the vitamin A group.

What about antibiotics? Antibiotics are felt to be safer, little evidence for this. One paper in guinea bissau, there were redicued incidence of pneumonia and conjuntivitis and greater weight gain in the abx.

47.1.4 Why is mortality higher in SSA than in Europe?

2% versus 0.05%

Is it a nourishment thing? NO.

Secondary cases seem to have a higher mortality than initial cases. So higher contact/family groups have higher mortality. So overcrowding contributes to higher mortality.

Also lack of access to care for secondary infections.

47.2 Case Two: Hand Foot Syndrome of Sickle Cell Disease

Gambian Child 9 months, fever and crying for 2 days. Has been immunised. Everyone else in family has been fine. Child has been breast feeding and eating rice. Mum has been fine.

Swollen hand. No lymphadenopathy. No signs of bite or trauma. Hot and tender foot.

Everything else has been fine.

47.2.1 Investigations

  • Malaria
  • Urinalysis
  • Haemaglobin/Film - Sickle CElls
  • Hb Electrophoresis
  • Blood cultures: Non-typhoid Salmonella

47.2.2 Risks

  • Chest Crisis
  • Stroke

47.2.3 Management

  • Analgesia
  • Hydration
  • Keep Warm
  • Antibiotics (Febrile and Unwell)
  • Folic Acid (they’re often folic acid deficient, as they turn over their cells faster)

  • Oxygen (to reduce risk of sickle crisis)

  • Immunise (s. pneumoniae, h. influenzae)
  • Education for parents

  • Hydroxyurea (if you can get it)

47.3 Case 3 - Yaws

8 year boy

Painful swelling of finger on hands.

Painless ulcers face and legs.

Most others in class at school have these skin lesions

47.3.1 Investigations:

  • Point of care HIV
  • Skin swab
  • Point of care treponemal test positive

47.3.2 Treponema Pallidum

Indistinguishable from syphilis on microscopy.

Spread from skin to skin contact. In hot/humid conditions.

47.3.3 Management

WHO tried to eradicate in 1952. Went to endemic areas and did VDRLs. Gave entire village benzathine penicillins as a single shot.

Azithromycin versus Benzathine Benzylpenicillin. Showed equally effective in 2012.

Now WHO is trying to eradicate with azithromycin