Day 5: TB, yellow fever.

Firstly, below is what the buffet setup is every morning, I dream about breakfast before going to bed. The variety is great!

All fun dishes on both sides!

Today was honey pancakes!

The morning talks were about tuberculosis. I learned that in India, if you go to a government affiliated center your drugs are free, but given some of the stigma people often go to a private physician. This also is an issue as previously this would go unreported, thus underestimated the burden of disease.  In India, given the high amount of TB, when people come to the hospital with just about any chronic symptom, TB is high on the differential. Infectious disease attendings and fellows from India have seen it everywhere. It is generally treated the same way, however directly observed therapy is not the norm, also patient’s usually are given therapy without regular lab monitoring (which isn’t necessary per Jan 2016 guidelines – but most do it monthly).

The lab portion today was super interesting, they have pretty sophisticated set up for looking for TB, they use immunofluorescence for their AFB smears, they also screen with GeneXpert/Rif to look for MDR TB. They also have a PCR screen if the GeneXpert is positive that detects for many more genes of resistance for first line agents.  Cultures are also placed in an incubator that detects TB much fast, and also grown on Löwenstein–Jensen medium and they had an example of TB growing the so called rough, buff, and tough.

This lab also included stations on mycology, crypto, histo, penicillium, pneumocystis, different candida, it was a great look at behind the scenes stuff and many microbiologists (mycologists) present who were eager to explain things.

In the afternoon, we had an interesting talk on yellow fever. Going over some of the history, how it was originally in Africa, and spread to South Africa through the slave trade. There have been multiple outbreaks the last one being in Angola 2016 where mass vaccination was done, to the point where vaccine doses were divded into 5ths in order to provide more vaccination.

So what does this do? Majority of people will have a flu like illness, incubation period is around 3-6 days; mylagias, fever, conjunctival injection. Around 15% go into a toxic phase, with jaundice, abdominal pain, vomiting, and of these people, ~50 die – bleeding via mouth, eyes, and liver failure. etc.

There is a very efficient vaccine, where 99% of people are protected essentially life long. Previously, it was recommended to get this every 10 years, now the WHO feels a one time vaccination is sufficient. The issue that was brought up is that some countries may still require this to be every 10 years, you might not be able to get into a country or leave a country (depending on where you are going).

One side effect worth mentioning which is very rare is viscerotropic disease, which is similar to wild-type yellow fever and has an ~60% mortality, it occurs about 0.4/100,000 persons. It can also cause neuro symptoms – meningoencephalitis, GBS, and ADEM – I am certain on my ABIM a question was asked about this.

Clinical portion:

Today my group went with Dr. Libman to see cases on the ward. He is an expert in tropical diseases and brought up some great points. The first case was a 45 year old male, alcoholic, came in with fever for 3 weeks and gradually worsening right upper quadrant pain. We went over a differential for fever in this situation, he again reiterated that this could always be malaria, he often asks about daily fevers vs periodic which may be helpful. His US showed a 6 x 9 liver abscess, it was felt this was highly suspicious for amebic liver abscess. He pointed out how the “anchovy” past that can be aspirated is dead tissue that is necrotic, but this is not a true abscess and doesn’t necessarily need to be drained. We also discussed the utility of stool looking for ameba, or serology is likely futile. In someone from a non-endemic place who was a returning traveler, this might be helpful. We also discussed the idea of giving a luminal agent, to ideally prevent spread to others, likely not useful in this situation.

Of note, patient’s with liver abscess often have fever and only develop pain once the capsule gets stretched, I saw a similar presentation to this in London. Liver abscess of any kind can also track up into the lung, and left sided abscesses can even get in the pericardium.

The next case was a 50 year old female who had 10 days of fever, headache, myalgias. On exam she had pointed out an eschar. She had elevated white count to 19 (with mainly PMNs), elevated bilirubin – she was found to be serology positive for scrub typhus, which is fairly common here.

The last case was a 40 year old male with fever x 10 days, he was afebrile on admission, review of systems only positive for fatigue. Found to be positive for P. vivax. He got chloroquine and should get primaquine this admission (after G6PD checked). We discussed how the fever often relates to merozoites escaping RBCs (schizonts), thus when he came in he had no fever, no schizonts were seen on peripheral smear which makes sense cause they’ve all escapes!