Frances Sanderson

Eosinophilia in returning travellers and migrants from the tropics: UK recommendations for investigation and initial management.

Eosinophilia is a common finding in returning travellers and migrants, and in this group it often indicates an underlying helminth infection. Infections are frequently either asymptomatic or associated with non-specific symptoms, but some can cause severe disease. Here the British Infection Society guidelines group reviews common and serious infectious causes of eosinophilia, and outlines a scheme for investigating returning travellers and migrants. All returning travellers and migrants with eosinophilia should be investigated with concentrated stool microscopy and strongyloides serology, in addition to tests specific to the region they have visited. Terminal urine microscopy and serology for schistosomiasis should also be performed in those returning from Africa. Eosinophilia is also a feature of significant non-infective conditions, which should be considered.

Fever in returned travellers presenting in the United Kingdom: recommendations for investigation and initial management.

International travel is increasing. Most physicians and general practitioners will encounter returned travellers with fever and the majority of travel-related infection is associated with travel to the tropics. In those returning from the tropics malaria must always be excluded, and HIV considered, from all settings. Common causes of non-malarial fever include from Africa rickettsial diseases, amoebic liver abscess and Katayama syndrome; from South and South East Asia, enteric fever and arboviral infection; from the Middle East, brucellosis and from the Horn of Africa visceral leishmaniasis. Other rare but important diseases from particular geographical areas include leptospirosis, trypanosomiasis and viral haemorrhagic fever. North and South America, Europe and Australia also have infections which are geographically concentrated. Empirical treatment may have to be started based on epidemiological probability of infection whilst waiting for results to return. The evidence base for much of the management of tropical infections is limited. These recommendations provide a pragmatic approach to the initial diagnosis and management of fever in returned travellers, based on evidence where it is available and on consensus of expert opinion where it is not. With early diagnosis and treatment the majority of patients with a potentially fatal infection related to travel will make a rapid and full recovery.

Science, medicine, and the future: Malaria

Malaria is one of the leading causes of morbidity and death worldwide, with over 100 million cases and at least a million deaths a year. Most of these deaths are in the poorest regions of the world. Because malaria is a highly complex disease, the diversity of research to prevent and treat it is probably greater than for any other disease. It ranges from modelling climate change and satellite data to predict epidemics through to elucidating the genome sequence of the malaria parasite Plasmodium falciparum and the mosquito vector Anopheles gambiae. The cultural diversity and poverty of seriously affected populations in Africa, Asia, and South America present particular challenges. Here social science, especially anthropology and economic research, have as important a role as traditional laboratory work. Malaria research is exciting because it is rapidly moving and cross disciplinary. It is also depressing, as the spread of drug resistant parasites, extreme poverty, and the collapse of health services under the impact of HIV or war undermine much of this progress.

How is income generated by outpatient parenteral antibiotic treatment (OPAT) in the UK? Analysis of payment tariffs for cellulitis

OBJECTIVES We determined the available mechanisms to generate income from outpatient parenteral antimicrobial therapy (OPAT) in the UK and calculated the revenue generated from treatment of an episode of cellulitis. METHODS Revenue was calculated for patients receiving treatment for cellulitis as an inpatient and for patients receiving OPAT by a series of different payment pathways. Selected established OPAT services in Northern Ireland, Scotland and Wales, where Payment-by-Results (PbR) does not operate, were contacted to determine individual national funding arrangements. RESULTS In England, a traditional inpatient episode for uncomplicated cellulitis requiring 7 days of treatment generated £1361 of revenue, while OPAT generated revenue ranging from £773 to £2084 for the same length of treatment depending on the payment pathway used. Treatment using OPAT to avoid admission entirely generated £2084, inpatient admission followed by transfer to a virtual OPAT ward at day 2 generated £1361 and inpatient admission followed by discharge from hospital to OPAT at day 2 generated £773. In Northern Ireland, Scotland and Wales block contracts were used and no income was calculable for an individual episode of cellulitis. CONCLUSIONS No single funding mechanism supports OPAT across the UK. In England, revenue generated by OPAT providers from treatment of cellulitis varied with the OPAT payment pathway used, but equalled or exceeded the income generated from equivalent inpatient care. Cost savings for OPAT and reuse of released inpatient beds will increase revenue further. A single OPAT tariff is proposed.

New therapies and changing patterns of treatment for malaria.

The launch of the Roll Back Malaria initiative by the World Health Organization in the period under review confirms malarias place as one of the great public health priorities worldwide. The period 1998-1999 has seen some advances and some disappointments in the treatment of malaria, against a backdrop of spreading drug resistance. Most encouraging is the clear demonstration that intermittent prospective treatment of asymptomatic pregnant women in endemic areas reduces morbidity. The greatest disappointment has been the result of trials with the artemether-benflumetol fixed-dose combination therapy. Questions have been raised about several widely accepted practices, including measurement of quinine levels, exchange transfusion, and the prophylactic use of anticonvulsants in children with cerebral malaria.

Acute transverse myelitis as a rare manifestation of Campylobacter diarrhoea with concomitant disruption of the blood brain barrier

We describe a case of acute transverse myelitis following Campylobacter diarrhoea in an adult. The patient presented with diplegia due to a longitudinal spinal cord lesion. The CSF demonstrated an aseptic meningitis. Oligoclonal bands and C. jejuni-specific IgG were detected in serum and cerebrospinal fluid at the beginning of the neurological illness. The patient was treated with antimicrobial therapy and steroids. A near full recovery was made and there were no relapses. C. jejuni is strongly implicated in the aetiology of acute motor axonal neuropathy and Miller Fisher syndrome through molecular mimicry of neuronal gangliosides. These gangliosides are expressed throughout the nervous system yet C. jejuni related central nervous system disease is exceedingly rare. We conclude that disruption of the blood-brain barrier was the key event in the pathogenesis of immune mediated post-infectious myelitis in our patient.

A young fit man presenting to the emergency department with a painful neck due to a thyroid abscess

### Learning Point for Clinicians This case exemplifies the need to consider less common diagnoses if a patient’s presentation is non-classical, such as in our patient who had an erythematous neck, unilateral thyroid lobe enlargement and grossly elevated white cell count and C-reactive protein (CRP) that would not be expected to occur with viral thyroiditis. A 38-year-old Caucasian man presented to our emergency department with a week’s history of sore throat, dysphagia, neck swelling and fever. One month prior, he experienced a respiratory tract infection, for which he had not sought medical advice and which had resolved without antibiotics. He had no history of trauma or procedures involving the neck. He had no notable past medical or family history. He was a non-smoker and drank 15 U of alcohol per week. On examination, he was a young fit man, slightly sweaty and flushed but otherwise looked …

Encephalitis: help from guidelines.

Physicians frequently bemoan the lack of effective therapeutic interventions in neurology. However, herpes simplex virus (HSV) encephalitis represents a medical success story: mortality in untreated HSV encephalitis is ≈70%—with high-dose intravenous acyclovir it falls to <20%.1 In the UK, acute encephalitis is a rare syndrome. Exact figures are not known despite the requirement by statute for notification of clinical suspicion. It can affect all age groups, with highest incidence in infants and those aged over 65 years. Most cases are sporadic. Recent data from England show that 42% had an infectious aetiology, 21% an immune-mediated cause, whereas 37% had no identifiable cause.2 One-quarter of the cases were caused by acyclovir-sensitive viruses (HSV type 1 and 2; varicella zoster virus). However, the morbidity and mortality was high across aetiologies, including those of unknown cause. Of those with HSV encephalitis, 11% died and at 6 months only 39% had a good outcome (Glasgow outcome score >4). The worst outcome was seen in patients identified retrospectively to have had an antibody-associated encephalitis (voltage-gated potassium channel antibody or N -methyl d-aspartate receptor antibody encephalitis). How can we improve outcome? For HSV …

Pituitary hCG production and cerebral tuberculosis mimicking disease progression during chemotherapy for an advanced ovarian germ cell tumour

BackgroundOvarian germ cell tumours (OGCT) are rare but are usually curable with chemotherapy, even when presenting with advanced disease. The majority of OGCT produce the tumour markers, hCG and/or AFP which can be helpful in the diagnosis and monitoring the response to treatment.Case PresentationIn this case of a 36 year old woman, the elevated hCG level at presentation was helpful in making a clinical diagnosis of OGCT in a patient too unwell to permit a tissue diagnosis.Cisplatin based combination chemotherapy produced an initial normalisation of the hCG level, but later in treatment the patient developed new cerebral lesions and a rising serum hCG suggestive of disease progression.Further investigations suggested that the CNS lesions were cerebral TB and that the low levels of hCG elevations was likely to be pituitary in origin. Chemotherapy treatment was continued along with anti-tuberculous therapy and 24 months after successful completion of therapy the patient remains disease free.ConclusionsIn the treatment of cancer patients it may be helpful to consider the potential non-malignant causes of new CNS lesions and that low hCG elevations may result from physiology rather than pathology in selected cases.