Showing papers in "Tropical Doctor in 1994"

The 'kangaroo-method' for treating low birth weight babies in a developing country.

Abstract: The results of introducing the 'kangaroo method' (constant nursing of the baby skin to skin on the mother's chest), as the exclusive means of treating low birth weight (LBW) babies is reported, in the context of a mission hospital in a developing country without incubators and standard equipment for care of LBW neonates. Details of the method developed are described. The survival of babies born under 1500 g improved from 10% to 50%, whereas that of babies 1500-1999 g improved from 70% to 90%. The method is well accepted by the community, and easily grasped by all hospital staff. Staff expectations concerning survival have dramatically improved, and a considerable saving in workload is experienced. The kangaroo method as described is strongly recommended to all units in developing countries treating LBW babies without modern equipment.

The quantitative buffy coat for the diagnosis of trypanosomes.

Abstract: The use of quantitative buffy coat (QBC®) tubes developed for malaria diagnosis is described in the diagnosis of African trypanosomiasis. One hundred and thirty-four patients with Trypanosoma gambiense were examined using QBC® plus either haematocrit (HCT) or mini anion exchange centrifugation (MAEC) or both. QBC® was the only method that detected all 134 patients. QBC® proved to be the most sensitive diagnostic test for the detection of trypanosomes in blood. It is simple to use, gives fast results and would be a useful test at the district hospital level.

Rapid rural appraisal.

Abstract: Sexual abuse of children in rural Zimbabwe: a report from Elim Hospital Two young girls have recently been seen at Elim Hospital suffering from vaginal gonorrhoea. The first presented with suprapubic pain and perivulval skin irritation. Only on a later visit was the history of vaginal discharge elicited. Gram stain revealed the presence of gram negative, intracellular diplococci. The possibility of sexual abuse was raised with the mother. She stated that this was, in fact, her suspicion although she had not previously suggested this possibility. Despite investigations by the police the culprit has not been identified. The child was 4 years of age. The second patient was brought by the police with a history that the child had been raped by a 21-year-oldneighbour. The child had a vaginal discharge. Gram stain showed the presence of gram negative, intracellular diplococci. This child was 7 years of age. Over the period January 1987to June 1993, 18 patients under the age of 16 were seen with a history of alleged rape/sexual abuse. The age range was 4-15 years. There were 17 females and one male. Of the female patients, nine (53070) were prepubertal. In 12 (71%) it was the opinion of the examining doctor that full penetrative intercourse had occurred. In two cases (11%) there was documented evidence of sexually transmitted disease. Two patients were pregnant. There were no documented cases of acquiring HIV infection in this group.

Cotrimoxazol in the treatment of Mycobacterium ulcerans infection (Buruli ulcer) in west Africa.

Abstract: Infection with Mycobacterium ulcerans causes a disforming disease, known as Buruli ulcer, which clusters near rivers or swamps of tropical or subtropical regions. It starts as a subcutaneous nodule or tender swelling, sometimes phlegmon-like with fever, and leads to a painless and chronic ulcer with characteristically undermined edges. Secondary infection is a common complication. Healing is protracted and results in hypertrophic scars leading often to contractures of neighbouring joints'. Diagnosis can be made in endemic areas on clinical findings and confirmed by direct microscopic examination of a wound smear stained by ZiehlNeelsen's method. Further diagnostic work-up (not generally available in rural Africa) includes culture of the wound smear on Lowenstein-Jensen media at 33°C for up to 12 weeks with repeated decontamination from faster growing organisms-, and histopathological examination'. Despite promising results in vitro\" and in laboratory animals' no effective antimicrobial treatment exists\". Radical excision of the affected tissue with macroscopically visible granulomata is curative in the majority of cases, but often disfiguring itself? The resulting skin defect usually has to be covered by a secondary skin graft. Cotrimoxazol has been reported to be effective in a number of casess-\", but has never been studied in a controlled trial. We evaluated cotrimoxazol in a series of cases from a rural district hospital near

Copper sulphate poisoning

Abstract: A number of cases of copper sulphate poisoning from the southern region of Bangladesh are presented. There was a high mortality (24.9%) in comparison to other forms of poisoning. Hepatotoxicity, acute renal failure and gastrointestinal bleeding were the main complications. This degree of copper sulphate poisoning in one particular area is cause for alarm.

Detection of Helicobacter pylori in endoscopic biopsies in Sudan.

Abstract: We studied the prevalence of Helicobacter pylori in Sudanese subjects with gastroduodenal inflammation. H. pylori was looked for in biopsy specimens taken from the antrum by two methods: rapid urease test [Campylobacter-like organism (CLO) test] and culture using Skirrow's selective supplement. One hundred subjects were studied. H. pylori was found in 80% of patients with gastritis, 56% of patients with duodenal ulcer, 60% of patients with duodenitis and 16% of normal control subjects. It was neither detected in patients with gastric ulcer, nor in patients with oesophagitis or in those with oesophageal varices due to schistosomiasis, when using culture. However, it was found in 50% of patients with oesophagitis, when using CLO test.

Prevalence of paediatric skin diseases in rural Honduras.

Abstract: Although review of medical literature suggests that skin disease is a common cause of morbidity in developing countries, there have been few prospective primary care studies to document the prevale...

The Health Consequences of Intrauterine Growth Retardation in Southwestern Ethiopia

Abstract: Although over 90% of low birth weight deliveries occur in the developing world, knowledge of its occurrence and consequences are largely based on studies in developed populations. The aim of this investigation was to determine the health consequences of intrauterine growth retardation (IUGR) among an historical cohort of children delivered in a regional hospital located in southwestern Ethiopia. Following a census of all births over a three year period 116 full-term, IUGR and normal birth weight (NBW) matched pairs between 3 and 40 months of age were identified. IUGR children were found to be at elevated risk for moderate to severe malnutrition [relative risk (RR) = 2.26 (1.15,4.43)], frequent illnesses (RR = 1.29 (1.13, 1.46)), and current illness (RR 1.52 (1.10, 2.09)). Catch-up growth among IUGR children did not occur. A steady decline in the growth of NBW children resulted in similar anthropometric outcomes by 2 years of age between the two groups.

The impact of training and supervision on traditional birth attendants.

Abstract: A survey of 40 trained and 40 untrained traditional birth attendants (TBAs) was done over a 3-week period in two counties in Uganda to evaluate the impact of training and supervision on TBAs. Forty womens' groups and 20 mothers were also interviewed. The result showed that the most utilized birth attendants were mothers-in-law, trained and untrained TBAs, and the pregnant woman herself. Childbirth was regarded as a normal, private event and the birth attendants were normally called when labour was well advanced or in case of complications. Trained TBAs were attending three times the number of deliveries as untrained TBAs. There was no difference in the knowledge and practices of trained and untrained TBAs, and in the performance of supervised versus unsupervised trained TBAs. All TBAs demonstrated poor knowledge and practices in the management of complications of pregnancy and labour. Reasons suggested for the poor performance included an over ambitious, inappropriate initial training, and lack of useful supervision. Overall the study concluded that there was a case for continuing with the training and supervision of TBAs provided changes were made to the selection, training and supervision processes.

Utility of arm circumference as a screening instrument to identify women at nutritional risk.

Abstract: Anthropometric measurements of 567 healthy nonpregnant women aged 20-40 years were studied to assess the utility of mid-upper-arm-circumference as a screening test to detect malnutrition. The prevalence of malnutrition in the study sample was 38.4%. A cut-off point of 24 cm was found to be most appropriate in the study setting as at that level the sensitivity, specificity and positive predictive values were 71.1%, 69.6% and 59.4%, respectively.

On the differences between post-kala-azar dermal leishmaniasis and leprosy.

Abstract: No other disorder mimics leprosy so well as post-kala-azar dermal leishmaniasis (PKDL) or Brahmachari's disease. In places where leprosy and kala-azar (KA) are major public health problems many would recall this misdiagnosis made by both medical and paramedical workers in the field of leprosy. Since PKDL is characterized by multiple skin lesions it is usually mistaken for the multibacillary forms of leprosy, frequently lepromatous leprosy (LL), sometimes borderline lepromatous (BL), and rarely mid-borderline (BB) leprosy. This article brings out the salient distinguishing features between the two diseases. PKDL is seen in 5% to 10% of patients generally 1-5 years after an attack of KA or rarely without a past episode of KA, and is prevalent in Bangladesh, India, Nepal and Pakistan I. From almost the very beginning/ till now 36 PKDL has frequently been mistaken for LL with the patients receiving antileprosy drugs for a prolonged period. Such cases that bore a remarkable resemblance were classified by some as the leprous type of PKDU. Kala-azar is endemic in parts of Africa but true PKDL is uncommon as the eruptions occur during or shortly after treatment of KA8• However, cases mistaken for leprosy and similar to those seen in the Indian subcontinent have recently been reported'\"!\". The clinical manifestations seen in PKDL and LL are multiple erythematous indurated lesions comprising papules, plaques and nodules, and hypopigmented macules. They are usually generalized, the face being predominantly affected11,12. Despite the similarity there are some differences that can be clinically appreciated and they are listed in Table 1 (see p 121). PKDL seen in Africa and in other places bears the same features except that in the former clustering of lesions in the centre of face is not so marked and there is histologic evidence of dermal nerve involvement in the absence of clinically detectable sensory deficit I3, 14.

The reasons for amputations in children (0-18 years) in a developing country.

Abstract: This study describes 49 young amputees who either have attended or have been operated at the Orthopaedic Department of Dodoma Regional Hospital from 1983 to 1991. Emphasis has been put on the aetiological factors of 56 amputations under review, underlying those that are typical of the Least Developed Countries in Africa and highlighting how they interrelate with the beliefs and traditions of the African society. Apart from 14 amputations performed for trauma of different type, important roles were played by home environment, tumours, wild animal bites and the health system itself. Nine amputations have been carried out for burns, while complications after medical care, particularly operative, have called for 12 amputations. Bone tumours have been responsible for eight and hyena assaults and snake bites have resulted in seven amputations. Special interest has been raised by four amputations performed for the so-called 'idiopathic tropical lower limbs gangrene' whose aetiology is still unknown. Language: en

Neuromyelitis optica (Devic's disease) following chicken pox.

Abstract: was extensor and the left was equivocal. There was hypoathesia on the left side of the body from the level of C4 downwards. Posterior column sensation was intact. He developed retention of urine on the day of admission. The haemoglobin concentration was 115 g/I: the total white blood count (WBC) 7.3 x 109/1; platelet 249x 1()'l/I; and urine examination normal. The monos pot and brucella agglutination test were negative. Computed tomography (CT) of the brain was normal. The cerebrospinal fluid (CSF) was clear, with a protein concentration of 815 mg/I; glucose 4 mmol/I (plasma glucose was 6.2 mmol/I); red cells 65 x 106/1; and WBC 38 x 106/1 with 90070 lymphocytes. The CSF protein electrophoresis showed no oligoclonal band. Blood urea serum creatinine and liver enzymes were normal. The parents refused myelography. A CT scan of the spinal cord without myelogram showed no cord compression. Serological tests for common viruses, including cytomegalovirus and Epstein-Barr virus, were negative in blood and CSF. Visual and auditory evoked response values were normal. Electromyogram and nerve conduction studies revealed no evidence of peripheral neuropathy. The patient was treated with dexamithasone for 6 weeks. He required a urinary catheter for the first 2 weeks. Eventually he made a complete recovery without neurological sequelae. Our final diagnosis was post vaccination BrownSequard syndrome affecting the cervical cord.

Rare poisoning with cerebra thevetia (yellow oleander): a report of three cases.

Abstract: The common oleanders, Thevetia peruviana (Pila Kaner) and Nerium-oleander contain a mixture of poisons including glycosides and are extremely toxic. They are widely cultivated as an ornamental shrub in the plains of India and have been used for the purpose of suicide, homicide, and as an abortifacient. We have come across three cases of suicidal poisoning with Pila Kaner in the last 9 months, an uncommon occurrence even for a major referral hospital such as ours.

The home-based health passport: a tool for primary health care.

Abstract: In Zambia home-based patient records were introduced on a pilot basis in Sesheke district in 1991. First health workers attended a one-day training session on how to use and maintain the home-based health passports. The passports were available on a fee basis. The sale of health passports created a revolving fund to address health-related stationery (e.g. referral slips) shortages. (These health passports contain curative and preventive records. Health passports for under-five children have a growth chart on its cover while those for older children and adults do not. Health workers enter the immunization status of women and children in the passport.) Four and 16 months after the passports were introduced household and health facility surveys were conducted to determine the views of patients and health workers about the passports. By four months 68% of the respondents purchased a passport. This had increased to 91% by 16 months. The average number of passports per household rose from 3.4 to 5.8 between the two surveys. By 16 months only 16 people (9%) did not have a passport. The price prevented two people (1%) from buying the passport. No one had lost a passport. 16% at four months and 14% at 16 months kept their records at the hospital largely because they did not want their passport to be damaged (e.g. rain damage). A plastic cover would protect the passport against damage. Confidentiality was not a problem for patients but health workers were concerned about it. Many respondents (36% at 4 months and 30% at 16 months) considered the passport to be expensive. Between the two surveys knowledge on the purpose of the growth chart on the childrens health passport increased from 38% to 48% (p < 0.05). This evaluation was so positive that health passports have been introduced in all districts in Western Province.

Obstetric uterine ruptures in a rural area in Zaïre.

Abstract: Uterine ruptures with their deplorable sequelae constitute a major obstetrical problem in the rural areas of Africa. The maternal and perinatal mortality remain high as a result, mainly due to the lack of early and adequate care for these patients. Grande-multiparity is one of the major predisposing factors. Prevention must necessarily include the availability of family planning advice, improved organization of and access to maternal care, and good supervision during delivery and the post-partum period. The general improvement of the overall socio-economic condition is a pre-condition to the improvement of access to care.

Is intrarectal injectable quinine a safe alternative to intramuscular injectable quinine

Abstract: An epidemic in Guinea Bissau On a hot day, just before lunch, a young lady brought me a letter from the nurse at Pecixe, which is a small island off the coast. At the time I was working in Guinea Bissau as district advisor for primary health care. The letter described how many people on the island had, during the previous week, presented with black sores and fever, with diarrhoea and dyspnoea. Some deaths had occurred among those affected. In addition, many cattle and goats had died. A few patients had been sent to the capital, Bissau. The bearer of the letter had been sent to me so that I might examine the black sore she had on her face. The nurse wondered if it might be a disease that had been transmitted through cattle, such as Brucellosis. She was asking for help and drugs. After consulting Manson's Tropical diseases, the laboratory technician and I looked at a smear from the ulcer, stained with Gram stain. Gram positive bacilli suggested anthrax. The district veterinary surgeon, the district medical officer, and the district nurse were made ready to visit the island, but the public health office in Bissau could not be reached by telephone. When we reached the island we were met by the public health officials from Bissau, who had arrived at the same time. They had already been alerted by the arrival at the hospital of anthrax cases. So large a medical invasion put strains on available accommodation and I had to share one of the few beds with a Cuban epidemiologist. We were able to supply huge stocks of penicillin, but the people had taken the initiative of wearing limes around their necks as a protection against the disease which was given a name in the local Mandjaco language (or dialect). Health education meetings in the villages were impressive and successful. The motivation for them to have their cattle inoculated was high. Unfortunately, the inhabitants had refused vaccination a year before, so there were no vaccines available, nor would there be for a year. Everyone recognized the disease in its early stages, and came quickly for penicillin treatment. During the first month, 57 human cases were reported, with 12 deaths.

Animal injuries presenting to Riyadh Armed Forces Hospital: a survey.

Abstract: Animal injuries presenting to Riyadh Armed Forces Hospital: a survey Our interest in human injuries inflicted by animals was recently stimulated when we treated a patient who had been bitten by a camel. The nature of this injury illustrated that the large domestic animals kept in this environment are capable of inflicting serious injuries. A subsequent Medline literature review unearthed many references on human injuries caused by small domestic animals, but little on those inflicted by large domestic beasts (camels, horses, cows, etc.). To investigate the incidence and epidemiology of such presentations at the Riyadh Armed Forces Hospital, a computer-aided search was made for all such attendances at this Hospital between the years 1984 and 1993. This yielded information on only 13 male patients, all of whom had been admitted for in-patient treatment. The ages of the 13 patients, most of whom were middleaged to elderly, ranged from 5 to 69 years. Ten patients were injured by camels, one by a kick from a horse and two presented with cat bites and scratches. Of those injured by camels, six had sustained kick-injuries which had caused fractures of long bones in three patients, a subarachnoid haemorrhage in one patient, a haemarthrosis of the knee in one patient and an acute abdominal injury in one patient. Two patients had been bitten by camels; one sustained a life-threatening neck injury, the other a shoulder injury which caused major vascular and bony injuries. One camel handler had sustained a rope-crush injury to the fingers, and another presented with a fractured leg subsequent to being knocked down and crushed by a camel. A further patient had been kicked by a horse, sustaining blunt abdominal trauma. Patients were managed according to the type and severity of injury. Fractures were reduced and fixated, and soft tissue injuries were explored and repaired as appropriate. Camel bites caused the two most serious injuries. The patient with left shoulder injury was managed by plating the clavicle and repair of the subclavian artery with Gortex graft'. The other bite injury was fatal. This patient developed a gangrenous left arm following a bite on the neck. The patient declined amputation and succumbed to the toxic effects of the infection. This illustrated the propensity of bite wounds to become infected", The duration of hospital stay varied from 5 days to 30 days, depending on the severity of the injury. Being an urban centre, our data almost certainly do not represent the national epidemiology of animal injuries, most of which would probably have presented at rural hospitals. Though it has been reported that injuries are likely to occur during the winter (mating) season", we could not confirm this. Furthermore, while camel bite injuries are more common elsewhere':", the commonest cause of injury presenting here was that due to the camel kick. Those who do sustain camel bites often present, as with one of our patients, with wounds on the Tropical Doctor, April 1994

Using lot quality assessment techniques to evaluate quality of data in a community-based health information system.

Abstract: We report here on the application of lot quality assessment (LQA) techniques by managers of a Save the Children (SC) Child Survival Project in Mbalachanda, Malawi, to evaluate data contained in a community-based health information system. By defining 'lots' as the health records for all households with children under 5 years old which were listed on the rosters of village health promoters supervised by a given community health supervisor, and by establishing criteria for 'acceptability' of samples drawn from these lots, we were able to identify and offer additional supervision to health workers (supervisors as well as village health promoters) who were not performing adequately. As LQA sampling procedures require that only a small sample be drawn from each lot, the assessment could be conducted easily and quickly. Health workers were found to have the greatest need for help in updating demographic data and information about home-based oral rehydration therapy (ORT) training sessions, and the least for help in recording children's immunization status. We conclude that LQA can be a useful supervisory tool for health programme managers.

Prevalence of parental medication on children before going to the hospital.

Abstract: RESULT There were seven patients, three males and four females, aged from 9 to 50 years. There were four parotid tumours (two ulcerated). All ipselateral facial nerves were compromized by malignant parotid tumours. There were two scalp tumours, both of which crossed the midline. All were fungating. Dimensions of the parotid tumours along their longest axes range from 15to 25 em; the scalp tumours measured 15em and 20 em. The mean haemoglobin concentration was 12 g/dl. Blood transfusion was not given in the immediate perioperative period, but one patient with a scalp tumour required 2 units of blood several days later. Two scalp and one parotid incision wounds were infected, two patients with dumbell meningeal tumours died 6 and 18weeks later from their diseases. One extensive squamous cell carcinoma of the scalp is still seen in clinic2 years later.

Evaluation of vitamin A deficiency in the Yelimane Circle of Mali, west Africa.

Abstract: Of 207 children (aged 4-7 years) in western Mali examined clinically and by conjunctival impression cytology (CIC), 2% had night blindness, no child had Bitot spots and 78% were found to have abnormal CIC suggesting deficiency in vitamin A. In a cohort of 53 children examined by CIC pre- and post-harvest (June and December), abnormal CIC were seen in 77.4% and 54.7%, respectively (P = 0.04). Subclinical vitamin A deficiency is a problem in this area. A seasonal variation is demonstrated. CIC is a useful method for identifying communities with subclinical vitamin A deficiency. A variety of strategies for dealing with vitamin A deficiency are discussed.

Sustaining health care in poor countries.

Abstract: Compiled by Michael E. Jones, Director, Care for Mission, Ellem Lodge, Duns TOll 3SG, Berwickshire, UK Non-OJ Vibrio cholera in Bangladesh Epidemics of cholera caused by Vibriocholerae01 occur regularly in Bangladesh but until recently Vibrio cholerae non-Ill has been associated only with sporadic cases of diarrhoeal disease in many parts of the world which include Bangladesh. In 1992 an epidemic in southern Bangladesh started spreading throughout the country and by the end of March 1993 had caused over 100000 cases of diarrhoea with nearly 1500 deaths. The disease was similar to cholera with similar response to treatment but in contrast to 01 cholera most cases were in adults suggesting that the population had no previous exposure to this organism. This organism did not belong to any of the known 138 vibrio cholera serogroups, so a new sere-group 0139 with the synonym Bengal was proposed. All the isolate studied produced an enterotoxin apparently identical to 01 cholera toxin. CHOLERA WORKIN(; GROUP. Large epidemic of cholera-like disease in Bangladesh caused by Vibrio cholerae 0139 synonym Bengal. Lancet 1993 ;342:387-90 Diphtheria after visiting Russia A 43-year-old healthy Finnish man visited St Petersburg in Russia for 3 days during Easter 1993. Twelve hours after he returned he became acutely ill and on admission to hospital large greyish membranes were seen on the hypopharynx and right tonsil which was necrotic. The pharynx and right side of the neck were heavily swollen, there was mild pyrexia and a moderate lcucytosis at 15.5 x 10/ 1. C-reactive protein was significantly elevated. Corynebacterium diphtheriae var gravis was identified and no other pathogens were found. As a result of the culture initial c1indamycin was changed to oral erthroymycin. Nine days after initial symptoms there was evidence of a myocarditis and 30 days after the development of the sore throat neurological Tropical Doctor, October 1994 28 World Bank. World Development Report: Investing in llealth. Washington DC: The World Bank, 1993 29 Brinkerhoff DW, Goldsmith AA. Promoting the sustainability of development institutions: a framework for strategy. World Dev 1991;20:369-83 30 Unicef. Sustainability: a challenge to sustain the gains of the child survival revolution. In: Meeting 011 Sustainability oj Health Programmes. New York, October 6-8 1991.

Bacteraemia in Blantyre.

Abstract: so as to reduce the sizeof hydrocele. He was born at home by vertex delivery, cried at birth and weighed 3500 g. There was tender, tense swelling of the scrotum, particularly on the right side. Differential diagnosis at that stage included bilateral haematocoele and torsion of testes. Sonography of the scrotum showed fluid of high echogenicity surrounding both testes. Exploration revealed that the fluid consisted of a large blood clot. The haematoma was evacuated and he was subsequently discharged well. This report highlights the need to be aware of trauma to testes by traditional means. This should be considered in the differential diagnosis of testicular swelling in neonates. S PRAM

Detrimental effects of high fluoride concentrations in drinking water on teeth in an endemic fluorosis area in south India.

Abstract: Fluorosis is a public health problem in India. It is due to excessive levels of fluoride (F) in water. Skeletal changes due to chronic F intoxication have been well described, but the dental effect known as 'mottled enamel', which is proportional to the fluoride content and duration of exposure, has received little attention. Epidemiologic data suggest that populations consuming traditional diets and high F in drinking water experience less dental caries. Because of these

Ventricular septal defect with endocarditis caused by Salmonella paratyphi A.

Abstract: CASE REPORT A 31-year-old woman presented with a history of low grade continuous fever of 10 days' duration without rigors, chills, cough, expectoration, urinary or bowel trouble. The patient was pale, but had no clubbing, cyanosis, jaundice, lymphadenopathy or peripheral signs of infective endocarditis. The optic fundi were normal. The supineblood pressurewas 110170 mmHg. There were no signs of heart failure. There was a systolic murmur of ventricular septal defect. The spleen was just palpable. Gynaecological examination was normal. The haemoglobin concentration was 8.5 g/dl, and the total leucocyte count 9.4x 109/1 (70% polyrnorphs, 16010 lymphocytes). Blood urea, glucose, electrolytes and stool examination were normal. The urine contained 10-12 red blood cells/high power field, and was sterileon culture. A Widal test was positive for Salmonella paratyphi AH in titres of 1:640. Blood culture yielded a growth of Salmonella paratyphi A. The electro-cardiogram had evidenceof left ventricular diastolic overload. The chest X-ray showed mildcardiacenlargement. A transthoracicechocardiogram demonstrated a subaortic ventricular septal defect with a thickened, tricuspid aortic valve. This was confirmed to be a vegetation on the right coronary cusp of the aortic valve by transoesophageal echocardiography. The patient was givenciprofloxacin750mg twicea day. She becameafebrile after about 10days of treatment. The blood culture became sterile and the titres of Salmonella paratyphi AH fell to 1:30 and then became negative. Salmonella typhi 0 titre was 1:120 which subsequently became negative. The treatment was continued for 6 weeks and the patient has been asymptomatic since then.

Pitfalls in the Diagnosis and Management of the Jaundiced Patient in the Tropics

Abstract: CASE REPORT 1 Presenting diagnosis 'recurrent hepatitis' A woman aged 30 years, previously diagnosed as having recurrent hepatitis, was seenin the out-patient department with jaundice. For severalyears she had experienced intermittent episodes of mild jaundice. Each episode lasted about 2 weeksand was not accompanied by itching, dark urine or pale stools. She took no regular drugs. On examination, she was mildly jaundiced but there were no other abnormalities. Dip-stick testing of urine showed no bilirubin. Serum liver function tests (LFTs) showed an unconjugated (indirect) bilirubin level of 31 JLmol/1 (normal < 17JLmol/I); serum transaminases, alkaline phosphatase and serum protein levels were normal. Haemoglobin was 14gldl and the reticulocyte count was 0.6010 (normal less than 2%).

Kingella kingae septicaemia in association with HIV disease.

Abstract: but is not practical for a large lesion with multiple discharging sinuses and creeping infiltrations. In our case simple excision was adequate for the small elbow lesions, but the large infiltrating lesions over the scapula and hip needed radical excision and appropriate grafting. The highly vascular flaps used to cover the excision sites may have changed the local blood flow pattern and prevented recurrence.