Tropical Cases

Problem one
• A 33-year-old female presents after admission to the
general medical/surgical hospital ward with a main
complaint of sudden onset, high fever (with shaking
chill or rigor and/or other systemic symptoms like
myalgia, arthralgia, headache, malaise), dyspnoea,
tachypnoea and cough productive of “rusty” sputum.
She reports that she was seen for similar symptoms
previously at her primary care physician’s office ten
months ago with more 10 other cases in that time in X
city which she is resident.
Write your differential diagnosis (please classify)
Respiratory system :( pneumonia all types:
Bacterial pneumonia
Aspiration pneumonia
Chemical pneumonia
Hospital aqurid infection
viral or atypical pneumonia )
TB
Lung abscess
GIT: ( may amebiasis spreading to lung)
Cardic :( myocarditis)
• On Clinical examination she mention there is chest
pain, her temperature were 38.2, pulse rate was 78, on
chest auscultation there is something abnormal in
specific part of lower left side. Please write 2 most
likely diagnosis
• A bacterial pneumonia
• B. Lungs abscess
• You sent the patient to investigation to confirm the diagnosis . Comment in CBC
test to support your first most likely diagnosis (A)
We see high numbers of WBCs totally and in differential neutrophils is high
………………………………………………………………………………………
• II. Comment on chest X ray, to exclude your most likely diagnosis (B) we see
consolidation as in A and in B has no consolidation we see Lungs abscess itslef
…
• … III. If you need farther test please write it with your expected result to
support one of most likely diagnosis
Sputum culture and sensitivity to confirm diagnosis and to selecting appropriate
treatment
• Please write your proper treatment for your most likely diagnosis (please put a circle A,B)
• Based on CURB 65 Score
A:
• If mild 1 of 5 give oral amoxicillin 500mg – 1g /8h or clarithromycin 500mg /12 h or doxycycline
200mg load and then 100 mg/day )5 days )

• If moderated 2 of 5 :same above pluse uf required iv give amoxicillin and clarithromycin 7 days

• If severe more than 3 give coamoxiclave 1,2 g/8h IV or Cephalosporins IV and clarithromycin Iv
for 7 days

• B : Sergical drining of abscess and if bacterial give antibiotics and if fungal give antifungal drugs
• Write the most important complication
• Septicaemia e.g meningitis
• Pleural effusion
• Empyema
• Lung abcess(if A)
• Write your prevention plan for population in X city.
• Adquate nutrition
• Pesonal hygiene
• Wearing mask
• Prophylaxis in HIV pt and in child

• Immunization :
• Pneumococcal conjugate vaccine (prevnar 13)
In babies Give 3-4 dose begin in 2 month old and final dose by 15 month
In adult above 65 one dose
• Pnumoccal polysaccharide vaccine
One dose against 23 kind of bacteria and it not recommended for children
Take the ppsv23 after one year from taking pcv13
19-64 year old who smoking should take vaccine
• Flu vaccine & Hib vaccine
Problem two
• Before few years, in Blue Nile state and you were the
medical officer in Alruwsirs hospital, you received 67
cases of severe dehydration and unfortunately 7 of
them was die. Some co-patients tell you there was
nausea, vomiting early in course of illness, before the
onset of diarrhea. The majority of the admitted patient
from same district.
• Write your differential diagnosis
• Food posining
• Cholera
• Shigellosis
• E-coli infection
• Gastritis
• You ask other co-patients about nature of diarrhea, and
they said “painless watery stool”. And on examination
most of the patients dehydrated, hypotensive and
drowsy. Please write your most likely diagnosis
• Cholera
• How did you confirm your diagnosis in situation like
this
• Stool general
• Cultere
• If no stool perform rectal swap
• Write your management plan “please write organize answer
to save the life of our patients”
• Gaol of mange to save a pt frist rehydration of pt due most
fatality rate due to vascular collapse
• Oral rehydration solutions if mild case
• By fluid like ringer lactate2-3 liter in first hour then followed
by normal saline one liter /h untial vital signs restore
• Antibiotice ciprofloxacin and tatracycline or doxycycline
Cont..
• If you calculate the total number of cases were 1000, but 102
of them were die. Please calculate the CFR of the disease
(remember at first time the deaths was 7 from total cases 67).
Make comment in variation of CFR
• Total 102 ÷1000×100=10%
• First time 7 ÷67 ×100=10%
• No difference between the two value indicates that the
control plane is Wrong and need to remodel this plane
• Write your prevention and control plan “please write your plan in categorical form”
• Isolation
• Enviromental :
• Water cholriation
• Santaion
• Control of files
• Personal hygiene
• Prophlxes :
• No vaccine available in Sudan But in out has active vaccine for cholera 1_live attenuated and 2 _toxoid
• Give Tetracycline For contact Prophylaxis
problem4
• A 20-year-old housewife presents to a hospital in northern
Uganda with a two-day history of fever, severe asthenia,
chest and abdominal pain, nausea, vomiting, diarrhoea
and slight non-productive cough. The patient is a Sudanese
refugee living in a camp in the region. She denies any
contact with sick people. Clinical Findings The patient was
prostrate and semi-conscious on admission. Vital signs
were: temperature 39.6°C, blood pressure 90/60 mmHg,
pulse 90 bpm, respiratory rate 24 breath cycles per minute.
Physical examination revealed, abdominal tenderness,
especially in the right upper quadrant hepatosplenomegaly
and bleeding from the gums. The lungs were clear. No rash
or lymphadenopathy was noted
 Questions
• Deferential diagnosis:
• Yellow fever
• Ebola
• Dengue hemorrhagic fever
• Crimean-congo hemorrhagic fever (CCHF)
• Chikungunya
• Lassa fever
• Malaria
• Typhoid fever
• Most likely diagnosis
• Ebola

• Investigation required
• CBC see low platelets cont due to consumption and increase in hematocrit due to leaks of plasma.
• BF for rule out malaria
• Bleeding time due to thrmbocytopeina
• ) tourniqate test )
• Confirmation test ---PCR and ELISA
• Management
Fliud replacment ( colloide solutions ) and paractamol
Antiviral drugs e.g ribovrin to stope spred of virs to other orgns
Fresh frosed plasma
Platlete to stope bleeding
RBCs in peckt form after pt restore and stable cheke CBC if RBCs low give RBCs
• Prevention measures
• Isolition
• Heath eduction
• Restriction of travel
• Avoid contact with animals
• Immunization
• Report to health authority ( notefiction )
• Control measures
• Mangment of dead body
• Tracing of contact
 Problem 5
• A 7-year-old girl who lives in Egypt , is brought to your clinic with
a lesion on the nose as the main complaint. The lesion appeared
four months ago as a small nodule and slowly turned into an
ulcer. It is a bit itchy but not painful. There is no history of
trauma.
• The girl is otherwise healthy. Six months ago she travelled to a
east Sudan to visit her uncle who work in agricultural crops.
Clinical Findings The lesion is a localized ulcer on the nose . The
borders of the ulcer are indurated and there is plaque-like
infiltration of the surrounding skin. The diameter of the whole
lesion is about 2 cm. There are no palpable lymph nodes. Body
temperature is 37°C. The rest of the physical examination is
normal.
Question
• Deferential diagnosis
• Cutaneous Leishminasis
• Syphlis
• Skin cancr
• Leprosy
• TB
• Actinmycosis
• Bactrial dermatitis
• Most likely diagnosis
• Cutaneous Leishminasis
• Investigation required
• Blood smear see amstgoites
• Biopsy from border of ulcer
• Culture
• Leishmanin skin test ( montengro test (
• Confirmation test
find amstgoitse in blood smeer and biobsy
PCR
• Management
• Sodium stibogluconate in ICU due to cardiotoxic effect
• Topical crème for skine
• Prevention measures
• Vector control
• Health eduction
• aviod contact with infcted person
• Control measures
• Report to local health authority
• Eerly detection and tretment
• Specific tratment
 Problem 6
• A 29-year-old man comes to your clinic in The Gambia
complaining of painful sores involving his private parts for
seven days. He has been previously well. He admits to having
had sex with a commercial sex worker two weeks ago, when
he had not used a condom. Clinical Findings He is in
considerable pain and is only able to walk with difficulty
because of this. He is afebrile and well nourished. General
examination is unremarkable. The only abnormality is the
presence of numerous painful ulcers on his penis, scrotum and
inner thigh The ulcers are tender, soft and bleed on contact.
There is no inguinal lymphadenopathy
Question
• Deferential diagnosis
• Syphlis
• Chancroid
• Herpes gentalis
• TB
• Most likely diagnosis
• Chancroid
• Investigation required
• Ulcer biopsy swap for see haemophilus durcyi bactria
• Other test asking HIV and HBV and Syphlis ( for possplie co infection )
• CBC see netrophils
• Confirmation test
• Culter and antibiotic sensitvity ==Chancrid resist to penclline but syphilis sensitive to pencinllne for this
reasone perform culter and sensitivty
• Serology haemophilus durcyi bactria antgen
• PCR
• Management
• Azthromycin
• Erthromycin
• Ciprofloxucin
• Prevention measures
• Abstinence
• Be faithful
• Use condom
• Control measures
• Notefication (report )
• Tertment of cases
• Tretment of partner
Problem 7
• A 16-year-old girl from Algazeera state presents to the
emergency room of a hospital because of fever, generalized
abdominal pain and frontal headache for the past five days.
There is no history of diarrhoea. She delivered a baby five
months ago. A HIV test done in the antenatal clinic was
negative. Her further past medical history is unremarkable.
She lives with her parents, her three siblings and her baby in
an urban high-density area. There is no running water and no
electricity in the house. They fetch water from a community
tap. She went to primary school but recently dropped out
during her pregnancy.
• Clinical Findings
The patient is a 16-year-old girl in a fair nutritional state.
Temperature 38.1°C, blood pressure 110/60 mmHg, pulse 78
bpm, respiratory rate 20 breath cycles per minute, Glasgow
Coma Scale 15/15. There is mild scleral jaundice, no neck
stiffness. The examination of the abdomen shows diffuse
tenderness but no guarding. The liver is not enlarged, the
spleen is palpable at 2 cm below the left costal margin. The
chest is clear and there is no lymphadenopathy. Pelvic
examination is unremarkable and there is no vaginal discharge
Question ‫الي بالغامق اقرب‬
‫الحاالت يعني لو غيرت‬
• Deferential diagnosis Symptom
• uncomplicated Malaria most fectures can be spported it ‫وحدة‬
• Typhoid fever (no mild jaundice and splennomegly unlikly but WBCs ‫ممكن تتغير الحالة‬
may spport it)
‫لوحدة منهن‬
• Veciral leshmaniasis ( heatomegaly shold be present )
• Brucellosis ( no night sweat ond fever intermitent with projctial vomting )
• Spesis
• Shistosomiasis ( no hematouria and no history of water contact in agriculter)
• Hepatitis ( sever janudce not mild )
• Ambiasis ( no bloody diarrhia (amibic desntary))
• UTI (nuasea and vomtinig with fever and burning sensetion in mictruction
(urination )
• Infective endocarditis( no history of upper respiroty tract infection )
• Most likely diagnosis
• Uncomplicatrd Malaria
• Investigation required
• Bf = thick smear for organisme and thin smear for species) gemisa stain(
• Using rapid malaria antgen
• PCR
• ELISA for falciprum spp
• CBC
• Confirmation test
- Bf = thick smear for organisme and thin smear for species gemisa stain
- PCR
• Management
• Supportive teratment (antipyrtic and rehydration and anticonvulsantes
Treat hypoglyciemia )
• Coartem in uncomilcated form
• Arteesunate injction (in severe and co-species infection )
• Quinine if no hypoglycemia
• Prevention measures
1-Early diagnosis effective treatment .
2-insecticide_ treated mosquito net (ITN)
3-Indoor residual spraying (IRS) .
4-Control of larval stages by eliminate of mosquito breeding
site(biological ,chemical ,physiological ) .
5-In epidemic-prone areas, malaria surveillance should based on weekly reporting.
• Control measures
 Finding of the case.
 reporting to local health authority .
 isolation for hospitalized Pt .
 treatment .
Problem 8
• You are on-call in a London hospital and are referred a 31-year-old
HIV-positive man from Accident and Emergency. He has a six-week
history of drenching night sweats, dry cough and increasing
shortness of breath on exertion. He also reports general fatigue and
a loss of about 10 kg in weight over the past five months. He works in
the retail industry and travels extensively for business. In the past six
months he has had work trips to Europe, China, Korea, Japan,
Singapore and the United States. He lives with his partner, denies any
recreational drug use and has never smoked tobacco. He was
diagnosed with HIV six years ago. He says that one month ago his
CD4 was 280/µL. He is not yet on antiretroviral therapy (ART), or
any other regular medications. There is no other significant past
medical history
• he is alert, short of breath at rest but able to complete full
sentences. He has a temperature of 39.2°C. Respiratory rate
is 26 breath cycles per minute, oxygen saturation is 87% on
air, 97% on 15 L O2 via reservoir bag. Pulse 100 bpm, blood
pressure 120/70 mmHg. Chest is clear on auscultation. The
rest of the physical examination is unremarkable.
Question
• Deferential diagnosis
• Pnumonia esp; opportunistic pnumonia (pnumocyctis carnii or fungal pnumonia )
• TB( no prudactive caugh)
• Lung abcess ( no prudactive caugh)
• Bronchoitits ( no prudactive caugh and whessing )
• Pnemothorax (no trauma history )
• Most likely diagnosis
• opportunistic pnumonia because HIV Infections
• Investigation required
• CBC low WBCs : CD4 low than 200
• Lungs swap
• X-ray see diffuse grand glass apparnce
• Lung biopsy see honecomb appernce
• Cultere and sensitivty
• Confirmation test
• Cultere and sensitivty
• Management
• Antibiotic and antifungal
• Treatment of ART for HIV
Prevention measures
1-Among immunosuppressed patients, especially those with HIV infection,
those treated for lymphatic leukaemia and those with organ transplants,
2-prophylaxis with either oral trimethoprim-sulfamethoxazole
• Control measures
1-Report to local health authority
2-Concurrent disinfection: Insufficient knowledge.
3-Specific treatment: Trimethoprim-sulfamethoxazole is the
drug of choice. Alternate drugs are pentamidine (IM or IV)
Problem 9
• A 16-year-old girl presents to the outpatient
department of an urban hospital in Kassala having had
fevers of 39–40°C, headache, lethargy and muscle
aches for five days. Today she has vomited three times
and is complaining of abdominal pain. She also
noticed some bleeding from her gums after brushing
her teeth this morning. She is normally fit and well and
has not travelled outside the city.
• CLINICAL FINDINGS
• On examination, the patient looks lethargic but has a GCS of
15/15. Her temperature is 37.5°C, blood pressure is 94/68
mmHg, pulse 88 bpm and the respiratory rate is 20 breath
cycles per minute. There is a maculopapular rash on the
chest, abdomen and extremities that is fading (Figure 9-1).
Cardiovascular and respiratory examination is normal. There
is mild abdominal tenderness and the liver edge is palpable,
bowel sounds are normal. The spleen is not enlarged and
there is no palpable lymphadenopathy.
Question
• Deferential diagnosis
• Yellow fever
• Dengue hemorrhagic fever
• Chikungunya
• Malaria
• Lassa fever
• Typhoid fever
• brusellosis
• Most likely diagnosis
• Dengue hemorrhagic fever due to symptoms and endmic in kassala
• Investigation required
• CBC see low platelets cont due to consumption and increase in hematocrit due to leaks of
plasma.
• BF for rule out malaria
• Bleeding time due to thrmbocytopeina
• ) tourniqate test )
• Confirmation test
• PCR and ELISA
• Management
• Fluid plus antipyrtic viatl signs keep normal
• Anti viral
• Avoid asprin tretment to pt
• Prevention measures
• Heath eduction Educate the public and promote behaviours to remove, destroy or
manage mosquito vector larval habitats
• Restriction of travel
• Vector control on mosqutio
• Control measures
• Report to health authority ( notefiction )
• No Isolation just contral mosqutio by net
• Specific treatment: Supportive, including oral rehydration. Acetylsalicylic acid (aspirin) is
contraindicated because of its hemorrhagic potential.