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Plague, pests and parasites: living it up in Brazil

Plague, pests and parasites: living it up in Brazil. A series of fortunate events. Applied Zoology Leeds Uni, MPhil Nematology BMS World Mission to Brazil Dr. Fraga – specialist in Leishmaniasis 350 morning clinics Peak season – Leishmaniasis Triage, assessment, home visits, follow-up

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Plague, pests and parasites: living it up in Brazil

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  1. Plague, pests and parasites: living it up in Brazil

  2. A series of fortunate events • Applied Zoology Leeds Uni, MPhil Nematology • BMS World Mission to Brazil • Dr. Fraga – specialist in Leishmaniasis • 350 morning clinics • Peak season – Leishmaniasis • Triage, assessment, home visits, follow-up • Low season – dermatology, NTDs • Plague, Schistosomiasis, Leprosy, Chagas’, Rabies, Trachoma, bites, CLM, worms, scabies

  3. Chagas’ Disease

  4. Chagas’ Disease • American trypanosomiasis: Trypanosoma cruzi • Reduviid bug vector – ‘kissing bugs’ • Night-feeders (bed nets very useful) • Parasites in faeces – enter wound; rarely by ingestion (SC, Brazil, 2005, 100 cases) • Acute phase – often with chagoma • Chronic phase – neuronal and smooth muscle damage in heart and GI tract; premature death

  5. Xenodiagnosis

  6. Follicular trachoma

  7. Trachoma • Chlamydia trachomatis serovars A,B,Ba,C • Spread by contact with infective material • Primary schools – potential rapid spread • Much of Africa and SE Asia • 150 million affected; 5.6 million eye lesions • Intense foreign-body sensation, lacrimation • Oral azithromycin>tetracycline ointment

  8. Leishmaniasis • Imported cases increasing in UK, mostly from Latin America • Leishmania brasiliensis - mucocutaneous • 1,000 per 10,000 over 10 year study • Early detection and treatment • Notifiable disease • Field studies from Germany and USA

  9. Typical sandfly country

  10. Taipa houses make popular destinations

  11. Sand fly filling up

  12. Life cycle in brief • Promastigotes injected with sandfly saliva • Penetrate local tissue macrophages • Become amastigotes • Asexual multiplication – ‘cell nests’ • Rupture – into other macrophages • May disseminate - reticuloendothelial • Back to sandfly – reproduce again

  13. Amastigotes in macrophages

  14. Very typical lesion

  15. Volcano-like

  16. Easily confused

  17. Usually on exposed areas

  18. Some lesions very discrete

  19. Others extremely noticeable

  20. Raised borders typical

  21. Tissue erosion

  22. Atypical lesion

  23. Dry lesion

  24. Scarring not inevitable

  25. Regional lymphadenopathy 1

  26. Regional lymphadenopathy 2

  27. Regional lymphadenopathy 3

  28. Regional lymphadenopathy 4

  29. Montenegro test - intradermal

  30. Reading 48-72 hrs with biro pen

  31. Sodium stibogluconate treatment: painful and hepatotoxic

  32. Trial of new thermotherapy

  33. Presentation with mucosal involvement

  34. Remarkable recovery; still needs a dentist

  35. Suspicious lesions • Contact ID ward or HTD in London • PCR test – species-specific primers • Treatment depends on species • Blum et al., (2004) Treatment of cutaneous leishmaniasis among travellers. J. Antimicrobial Chemotherapy 53, 158-66

  36. Leeds student: post-Gap year • Belize, Guatemala inc. rain forest • Lesion on elbow • Axillary lymphadenopathy • Antibiotics cleaned wound, didn’t heal • Referral to ID ward, suspected leishmaniasis • Confirmed L.mexicana – itraconazole and intra-lesional sodium stibogluconate injections

  37. Intra-lesional injections

  38. Plague – the one that got away

  39. Students in Brazil

  40. Students in Brazil

  41. Case studies – students in Brazil • 22 year old male • 1 month stay, well throughout • On arrival back home: • Fever, headache, myalgia, loss of appetite: felt very ill • GP twice, ended up in hospital • Didn’t let us know until better

  42. Dengue Fever • Endemic in many regions, esp. Latin America and SE Asia – 100 million annually • Useful to know incidence rates – Dengue surveillance • Similar to other diseases – e.g. malaria, leptospirosis (important to rule out) • Normally one bad week and recover • Post–dengue fatigue not uncommon, can last months

  43. Case study 2 • 2 young females • 3 week stay; wedding function – D&V • One mostly V: short, acute very nasty • Other mostly D: prolonged acute illness • Stool culture • Ongoing illness in D – 9 months, full recovery some years later

  44. Post-infectious IBS • After acute bacterial gastroenteritis, up to one third will have prolonged GI complaints • PI-IBS documented after Campylobacter,Shigella, Salmonella, path. E.coli • Acute phase > 3 weeks: 11-fold increased risk of PI-IBS • Vomiting may decrease pathogen load on distal GI tract • Rule out other pathogens – e.g. Giardia

  45. PI-IBS reference • DuPont, A.W. (2008) Postinfectious Irritable Bowel Syndrome. Clinical Infectious Diseases 46, 594-9

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