Mycetoma

Virtual Doctors Work

As we move from Summer to Autumn in the UK and we see rain causing so much disruption and devastation around the world, I wondered about the effects of the changing seasons on health in Zambia. Situated in the tropics, Zambia gets lots of strong sunlight, but the intense heat that comes in the tropics is moderated here by the altitude and rainfall. There are two main seasons in Zambia, the rainy season (November to April), and the dry season (May to October/November). The dry season is divided into a cool and a hot time. The rainy and dry seasons are clearly distinct- with no rain falling at all in June, July and August (usually) followed by hot, wet downpours. Much of life is dominated by the start and end of the rainy season or ‘emerald season’ as it is known and the amount of water it brings. Failure of the rains to come can cause famine. The highest rainfall is in the north with the driest areas in the far southwest and the Luangwa River. Rainfall varies over a range of 500- 1400mm per year.

Flooding occurs every year on the floodplains. Those living in these areas, both people and wildlife, are well adapted to cope with this. However untarred roads become quagmires, many completely impassable. Rivers swell and burst their banks washing away trees, roads and bridges. Many rural areas can be cut off for a few months, making getting anywhere away from the main routes very difficult!

For this month’s case we return again to the Lusaka province which sits on the Zambezi flood plains. This time to Kanakantapa Rural District Health Centre in Chongwe district. Kanakantapa Rural Health Centre serves over 13,000 people from the surrounding communities which are predominantly farming areas. The Kanakantapa river lies to the west of Kanakantapa. It is crossable in the dry season but during the rainy season when the water levels rise and as there is no bridge it becomes impassable, increasing the distance to get to Chongwe by 5 km.

Lusaka Province showing Chongwe distict

Within Chongwe district we support 2 rural health centre and the district hospital.

The difficulties travelling to Kanakantapa clinic after a downpour.

Kanakantapa Rural Health centre

To the clinic, a mother brought her 2 year 11 month old boy to be seen. He is suffering from sores on his feet which have a watery discharge. These sores apparently often return during the rainy season. The clinical officer (CO) had seen quite a few cases like this and was struggling to treat them. For this child he had tried 2 courses of antibiotics; one oral and the next intramuscular (injection into the muscle) with no improvement. The CO included some good quality photos. These are so helpful in skin cases.

The Virtual Doctor (VDr) wasn’t entirely sure what the diagnosis was. But, as it was a particular rainy season problem and antibiotics hadn’t worked, thought it was likely to be a fungal infection. She advised starting some antifugal medicine by mouth. The advice was gratefully received although the clinic had limited supplies so the CO would have to order some medication to be sent. Tricky in the rainy season.

Meanwhile the VDr asked for a second opinion from a dermatologist in the UK. This condition is something not seen in the UK. The dermatologist thought that is was most likely to be Mycetoma. Advice was for further investigation to distinguish between a bacterial and fungal cause of the infection.This could be done by taking a potassium hydroxide slide of the discharge and seeing if fungal elements or filamentous bacteria could be seen under a microscope. A relatively low tech investigation to perform. And then to treat with antifungal medication if fungus was seen. The nails on the patient’s left foot looked abnormal  (dystrophic), suggesting a fungal infection. The dermatologist suggested trying treatment but noted that the response to treatment in this infection is generally poor.

What is Mycetoma?

Mycetoma is an uncommon chronic, infective skin and subcutaneous (tissues beneath the skin) disease. It presents with painless lumps under the skin, starting small they can grow, break down and form sores which ooze pus. It can cause the affected limb to become deformed or unusable. If left untreated or treatment fails, it can spread to other areas of the body. Sometimes surgery is needed to cut away infected tissue. Long- term it can destroy underlying muscle and bone. It most commonly affects the foot and it is also known as ‘Madura foot’ after the Indian region where it was first described in 1842. It is a health problem in equatorial regions of Africa, Latin America and Asia known as the ‘mycetoma belt’.

What Causes Mycetoma?

The source of this infection is found in the soil and water and is caused by certain types of both bacteria and fungi. It is likely they enter the body through breaks in the skin. Typically it presents in agricultural workers or those who walk barefoot. It develops over time as it requires repeated exposure of broken skin to the soil and water that contains the microbes. Fungal mycetoma (eumycetoma) is the most common type in Africa. Mycetoma does not spread between people.

Diagnosis and Treatment.

Mycetoma is best diagnosed by taking a small sample (biopsy) of the affected area of the body or the discharge and examined under a microscope to help determine if the infection is caused by bacteria or fungi. Cultures (growing the bacteria or fungi in a laboratory) from the discharge or biopsy can determine the specific type of microbe. Further imaging maybe needed to see how much damage to underlying muscle and bone has occurred.

Treatment depends on whether it is a bacterial or fungal cause:

Bacterial or Actinomycetomais usually treated with antibiotics and surgery generally not required.

Fungal or Eumycetoma is treated with long term anti-fungal medication, but sadly treatment may not be completely effective. If this is the case then surgery or amputation are sometimes needed.

So early diagnosis and treatment is vitally important and wearing shoes might help to prevent Mycetoma.

Disclaimer: This article is for information only and shouldn’t be used for diagnosis or treatment of medical conditions. If you have any concerns about your health consult a doctor or other health professional.

Snake Bite

The Virtual doctors work

Travelling to the Southern Province we find ourselves surrounded by agriculture and rural beauty. It is the home of Mosi-ao-Tunya (Victoria Falls) which Zambia shares with Zimbabwe. Formed by the Kariba Dam, Lake Kariba and the great Zambezi river run down the southern border of the province and in particular Siavonga district. Siavongo district lies at an elevation of 511m covering a land area of approximately 5,300 sq km. It had a population of 90,213 at the 2010 census but is likely to be in the region of 117,500 now. The town of Siavongo which houses the district hospital, is the principal tourism centre for the lake and is becoming known as the ‘Riviera of Zambia’. Travel approximately 100km from Siavonga and you arrive at Chaanga rural health centre where this month’s case arrived to be seen.

Southern Province. Siavongo is shown in pale blue on the eastern most corner

The Chaanga clinic

Virtual Doctors support 4 rural health centre throughout Siavongo district as well as the Siavongo district health team in the district hospital.

Clinical Officers training in Siavonga

Chaanga clinic was busy through February 2017. At the very start of the month the clinical officer saw a 9 year old boy who was brought in having had a snake bite to his leg. Two days after being bitten he had been taken to see a traditional healer and given some traditional treatment. Unfortunately this resulted in a large and infected wound. The Clinical Officer (CO) sent a patient file to the virtual doctors wanting to know how best to treat this. Examination revealed no loss in sensation to the affected area but a large infected wound.

The snake bite wound

The Virtual Doctors advice was to treat this wound like a burn. The wound was to be kept clean and dressed every 48 hours until granulation (healing) was seen. Antibiotics and pain relief was also recommended; antibiotics to be continued until the wound was fully healed. It is very important to prevent and treat infection to avoid further complications such as abscess formation or bone infection (osteomyelitis). These complications can result in amputation of the limb or to an overwhelming infection (sepsis) which can, if untreated, lead to death. Due to the nature of the wound it is likely this was a puff adder bite. This I will explain further below.

Fortunately in this case the patient was seen early receiving the right treatment and the CO was grateful for the advice, avoiding sending the patient to hospital and enabling him to be confident in managing this and future wounds.

Snakes in Zambia

There are many snakes in Zambia, most are harmless with just a few being venomous.  Fortunately most venomous snakes will often avoid humans and get out of the way when they feel the vibrations of your footsteps. If they do bite, they rarely inject their full venom load. Generally they only strike when they are surprised, cornered or threatened. The danger from snake bites and the toxicity of venom varies from species to species.

The most deadly snakes found in Zambia are:

African rock python- the largest snake in Africa, non-venomous common in rural areas reaching up to a 6m or more in length. It kills prey by constricting them.

Black Mamba- the longest venomous snake in Africa- up to 4.5m long. It is said by some to be the fastest snake in the world, able to travel at 20km/h! Its venom is neurotoxic.

Black- necked spitting cobra- quite common, sprays venom when cornered. Its venom is neurotoxic. Cover your eyes as theses snakes are short sighted and will spit at anything that glints! 

Puff Adder –common venomous snake. It is thought to be responsible for most bites to humans as it is well camouflaged, remains motionless and bites when unwittingly stepped on. The venom is cytotoxic.

Boomslang- a common green tree snake, venomous but timid. They produce a haemotoxic venom.  Boomslang bites are rare as these snakes are back fanged.  

Gaboon Viper- the largest viper. It is found in woodland, savanna and forests in the north of Zambia. Their venom is haemotoxic. They also have the longest fangs of any snake-each one almost as long as an adult’s little finger! They are rare.

Different kinds of Venom

Of these beautiful snakes above, the majority produce venom. Each venom has its own toxic effects.

The mambas and cobras neurotoxic venom attacks the central nervous system. The bite feels like a sting. It attacks the nerves, causing difficulty in movement, in breathing, swallowing and slurred speech and can cause death due to breathing difficulty.

The boomslang and Gaboon Viper produce haemotoxic venom which prevents the blood from clotting leading to extensive blood loss into the tissues. The bite is generally not too painful but within an hour bleeding starts from the bite and any other wounds or scratches the victim may have. Other symptoms can include a severe headache, nausea and vomiting.

The puff adder produces cytotoxic venom which attacks the body’s cells. The bite is instantly painful with immediate swelling, bruising and blistering. It can lead to break down of tissues over a wide area. Symptoms can include nausea and dizziness. It is likely our patient was bitten by a puff adder.

What to do about Snake bites

Anyone bitten by a poisonous snake must get professional treatment as quickly as possible. Symptoms usually show themselves fairly soon after a bite so observing the victim is very important.

First aid: Do not panic. The vast majority of snakes are not venomous and in the rare event of being bitten by a venomous snake most will not inject their full venom load.

Keep the victim calm and still, movement only increases blood flow and transporting of the venom more quickly.

Loosen the victims clothing and keep them shaded.

Immobilise the limb but do not restrict blood flow.

Clean the wound with plain water and dress the wound with a bandage but being careful not to apply pressure and cause bruising.

Be prepared to administer CPR if necessary.

If possible try to identify the snake, taking a photo as long as no one else puts themselves in danger. Pictures are useful for medical identification. Useful things to note are colour, size, shape of head and attacking method.

What NOT to do when a snake bites:

The advice for bites varies but the consensus about what not to do is pretty consistent:

Never use a tourniquet which cuts off the blood flow for this purpose.

Do not allow the victim to exercise or stress themselves

Do not cut or bite or attempt to suck the venom out.

Do not use potassium permanganate crystals or solutions near or on the bite wound nor use soapy water around the wound. Do not put ice or heat on the wound.

Do not leave the victim alone.

And finally it is worth remembering fatalities from bites are quite rare. When in the bush be careful and keep a look out. The more noise you make when walking the more chance the snake has to move off. Wear boots and long trousers. And remember shake your boots before putting them on!

Disclaimer: This article is for information only and shouldn’t be used for diagnosis or treatment of medical conditions. If you have any concerns about your health consult a doctor or other health professional.

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Sickle Cell Crisis

Virtual Doctors Work

This month our case comes from the Chongwe district found in the Lusaka province of Zambia. This district covers an area of 8669 square km, with a population of just under 250,000. It encompasses most of the lower Zambezi national park, an unspoilt area of wilderness. It sits on the Zambezi flood plain ringed by mountains. Chongwe is especially famous for its elephants which feed mostly on the winter acacia trees. The river not only supports the population but countless animal species too. This is a popular tourist area for adventurers.

Within Chongwe district we support 2 rural health centre and the district hospital.

Chongwe

Chongwe

Early in January 2017 a 2 year old boy was brought into Chongwe hospital by his mother. He was extremely unwell. He was known to have a condition called Sickle cell Disease. For the last 3 days his mother said he had fevers, swelling of his joints, cough, difficulty breathing, runny nose, diarrhoea, vomiting and poor appetite. He was on medication to prevent him from getting malaria (deltaprim) and folic acid to prevent him becoming anaemic (a complication of his underlying condition).  In his report to the Virtual doctors (VDrs), the clinical officer (CO) said the child looked ill with swollen joints and high fever. He had been started on an intravenous antibiotic, pain relief and a drip of fluid to treat dehydration. The clinical officer was concerned the boy was having a sickle cell crisis. Helpfully blood results were also sent showing the child to be severely anaemic (very low number of red blood cells). The Virtual Doctor agreed thinking the crisis was likely to have been triggered by a chest infection. She was, however, concerned that other diagnosis were considered, particularly malaria, to ensure the child was treated correctly.

After some more discussion The Virtual Doctor confirmed that the patient was receiving the right treatment and gave the CO more information to help manage the very ill patient and what to do if the patient's condition changed. The CO was working hard to look after this patient. During the day he updated the VDr with the good news that the patient was indeed improving and a few days later was well on the way to a full recovery.

What is Sickle Cell Disease?

Sickle cell disease (SCD) is a group of serious, inherited conditions which affects the blood and various organs of the body. It affects the red blood cells, which contain a special protein called haemoglobin which carries oxygen from the lungs to all parts of the body. People with SCD have sickle haemoglobin which is different from normal haemoglobin. When a sickle haemoglobin gives up its oxygen it sticks together inside the red blood cell making the cells rigid and sickle shaped (like a crescent moon) as can be seen in the picture below:

Because of their shape they can't squeeze through small blood vessels and block them stopping oxygen from reaching the places where it’s needed. This can lead to severe pain and organ damage. The sickling can happen suddenly causing symptoms which are known as a sickle cell crisis (as with our patient). Some conditions can trigger this such as a cold, infection or lack of body fluid (dehydration).

The red cells containing sickle haemoglobin also do not live as long as normal red blood cells leaving the person with a moderate and persistent anaemia. In between episodes of illness people with SCD generally feel well.

Who gets Sickle cell?

SCD is inherited. Two genes, one from each parent containing the information for sickle haemoglobin, is needed to have the disorder. If you only inherit one of these genes then you will have sickle cell trait which is much milder. Sickle cell trait does give the carrier some protection against malaria.

SCD and the different traits are mainly found in people whose family origins are African, Afro-Caribbean, Asian or Mediterranean. On average 1 in 2400 babies born in UK have SCD. In Zambia exact figures are hard to find, however, the world Health Organisation puts the figure between 5 -9.9 per 1000 births (for all the haemoglobin disorders) as seen on this map below: Sickle cell trait is thought to affect approximately 18% of the general Zambian population.

Global distribution of haemoglobin disorders in terms of births of affected infants per 1000 births

How Does SCD Present?

SCD can begin to cause problems between 3 and 6 months of age. The symptoms include anaemia, poor growth and increased susceptibility to infection. People with SCD are more prone to certain types of germ (bacteria) which cause pneumonia, meningitis, septicaemia or bone infections. (The usual culprits being pneumococcal, H.influenza type b and meningococcal). These infections can be life threatening particularly in the under 5 year age group. It is estimated that every day 500 children with SCD die in Africa and Asia due to overwhelming pneumococcal sepsis (overwhelming infection), malaria or unrecognised splenic sequestration (which occurs when a lot of sickled red cells get caught in the spleen causing severe pain and a sudden drop in haemoglobin).

Living with SCD

Symptoms of SCD come and go. There is a lot of individual variation in symptoms too. Some people are affected frequently and others rarely. Problems include episodes of pain, infections, acute chest syndrome where there are blocked blood vessels in the lungs and episodes of anaemia. Most organs can be affected.

Managing SCD

The treatment of SCD is a developing area of medicine.

Patients with SCD should be given a daily antibiotic to prevent infection (penicillin) particularly important in the vulnerable under 5s.

Immunisations of all the usual childhood vaccines plus meningitis and hepatitis B and flu vaccine are highly recommended in all age groups. Folic acid supplements are given to help the body make new red blood cells.

 In malarial areas it is important to take malaria protection medication and avoid mosquito bites.

To keep healthy it is recommended to keep well hydrated, regular exercise but avoid over exertion .It is important to keep warm.

Any signs of infection should be treated quickly.

Hyrdoxyurea taken regularly can help reduce the number of painful crises caused by the disease and to reduce the number of blood transfusions. It does require regular monitoring with blood tests due to its possible side effects. It was first used in chemotherapy.

Cure is only possible with a bone marrow transplant to replace the faulty stem cells which produce haemoglobin.

Sickle cell crisis

Treat with painkillers, hydration by mouth if possible but intravenous fluids if not, oxygen and antibiotics.

The Future

Currently the high number of deaths due to SCD in Africa and Asia are in the under 5 age group, often before diagnosis has been made. In the UK babies are tested at 5 days for SCD and other conditions. A blood spot is taken from a heel prick. Babies in the USA are also screened.

This is not the case in Africa, however, some countries are trying to address this. In Uganda for example they are considering the steps to make a national sickle cell program by building on the existing HIV program using dried blood spots. So exciting times in tackling non-communicable diseases.

Disclaimer: This article is for information only and shouldn’t be used for diagnosis or treatment of medical conditions. If you have any concerns about your health consult a doctor or other health professional.

Pellagra

Virtual Doctors Work

Found at the south eastern foot of a range of granite hills Kafue sits on the north bank of the Kafue river from which it takes its name. The district hospital covers the Kafue district an area of over 9000 square kilometres with a population of over 280,000.

Virtual Doctors support 7 rural health centres throughout Kafue district including the district hospital in town.

Kafue Ferry Crossing

During a busy clinic in November one of the Kafue based clinical officers saw a 42 year old lady. She had an itchy, painful rash around her neck and on her arms, hands and feet. This had been troubling her for 3 months and despite treatment was no better. The rash looked dry, peeling and was much darker than her normal skin. She was known to be HIV positive too.

The clinical officer sent off a patient file with some very helpful photos to Virtual Doctors. The Volunteer Virtual doctor felt this was likely to be a case of Pellagra. The reply was sent giving clear explanation and treatment advice.  Education was also given to help with ongoing learning and to improve treatment of other cases.

So, what is Pellagra? (“rough skin” from the Italian pelle agra)

Pellagra is a vitamin deficiency most often caused by a lack of niacin in the diet (Vitamin B3) and is characterised by the 4 D’s:  diarrhoea, dermatitis (skin rash), dementia and death.

First described by Gasper Casal in 1762 in Spain. He described the rash that he saw, particularly the hallmark rash around the neck which mimics a necklace and this is known as Casal’s necklace which you can see in the picture above (although slightly out of focus).

In the UK pellagra is rare but it is still common in Africa and particularly when untreated corn products are the main food source. In the 2000s there was outbreak of Pellagra in Zimbabwe. Other causes of Pellagra can be from alcohol abuse or medications particularly those used to treat tuberculosis. Patients with HIV infection can also develop a pellagra-like state. This may make it look like an easy diagnosis to make but the signs and symptoms evolve over time making the pattern harder to see.

Treatment is relatively simple with oral niacin (nicotinamide) which reverses the problems caused by the vitamin deficiency, the rash improving quickly. It is worth remembering that these patients may be malnourished and have other vitamin deficiencies so need a high protein diet and all B vitamins for a complete recovery.

Given the high incidence of HIV and TB in Zambia, Pellagra and pellagra- like states always need to be considered!