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Nye C, Lalloo DG, Hooper T. The use of rotational thromboelastometry to guide management following Bitis nasicornis envenoming. BMJ Case Rep 2024; 17:e258319. [PMID: 38589240 PMCID: PMC11015268 DOI: 10.1136/bcr-2023-258319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
A man in his thirties presented following Bitis nasicornis envenoming. His coagulation was assessed using rotational thromboelastometry (ROTEM). It identified a subtle abnormality, not detected using standard laboratory assessments of coagulation, and influenced ongoing management. The abnormality resolved following treatment with antivenom. There are few documented cases of using ROTEM to assess patients following haemotoxic envenoming. This case highlights some of the potential benefits and limitations of doing so.
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Affiliation(s)
- Charles Nye
- Neurology Department, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - David Griffith Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Timothy Hooper
- Department of Critical Care, NHS Highland, Inverness, UK
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2
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Ediriweera DS, Kasthuriratne A, Pathmeswaran A, Gunawardene NK, Jayamanne SF, Murray K, Iwamura T, Isbister G, Dawson A, Lalloo DG, de Silva HJ, Diggle PJ. Evaluating spatiotemporal dynamics of snakebite in Sri Lanka: Monthly incidence mapping from a national representative survey sample. PLoS Negl Trop Dis 2021; 15:e0009447. [PMID: 34061839 PMCID: PMC8195360 DOI: 10.1371/journal.pntd.0009447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 06/11/2021] [Accepted: 05/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Snakebite incidence shows both spatial and temporal variation. However, no study has evaluated spatiotemporal patterns of snakebites across a country or region in detail. We used a nationally representative population sample to evaluate spatiotemporal patterns of snakebite in Sri Lanka. METHODOLOGY We conducted a community-based cross-sectional survey representing all nine provinces of Sri Lanka. We interviewed 165 665 people (0.8% of the national population), and snakebite events reported by the respondents were recorded. Sri Lanka is an agricultural country; its central, southern and western parts receive rain mainly from Southwest monsoon (May to September) and northern and eastern parts receive rain mainly from Northeast monsoon (November to February). We developed spatiotemporal models using multivariate Poisson process modelling to explain monthly snakebite and envenoming incidences in the country. These models were developed at the provincial level to explain local spatiotemporal patterns. PRINCIPAL FINDINGS Snakebites and envenomings showed clear spatiotemporal patterns. Snakebite hotspots were found in North-Central, North-West, South-West and Eastern Sri Lanka. They exhibited biannual seasonal patterns except in South-Western inlands, which showed triannual seasonality. Envenoming hotspots were confined to North-Central, East and South-West parts of the country. Hotspots in North-Central regions showed triannual seasonal patterns and South-West regions had annual patterns. Hotspots remained persistent throughout the year in Eastern regions. The overall monthly snakebite and envenoming incidences in Sri Lanka were 39 (95%CI: 38-40) and 19 (95%CI: 13-30) per 100 000, respectively, translating into 110 000 (95%CI: 107 500-112 500) snakebites and 45 000 (95%CI: 32 000-73 000) envenomings in a calendar year. CONCLUSIONS/SIGNIFICANCE This study provides information on community-based monthly incidence of snakebites and envenomings over the whole country. Thus, it provides useful insights into healthcare decision-making, such as, prioritizing locations to establish specialized centres for snakebite management and allocating resources based on risk assessments which take into account both location and season.
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Affiliation(s)
| | | | | | | | | | - Kris Murray
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Takuya Iwamura
- Department of Forest Ecosystems and Society, College of Forestry, Oregon State University, Corvallis, Oregon, United States of America
| | - Geoffrey Isbister
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Waratah, Australia
| | - Andrew Dawson
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Addiction Medicine, Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | | | | | - Peter John Diggle
- CHICAS, Lancaster University Medical School, Lancaster, United Kingdom
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Goldstein E, Erinjery JJ, Martin G, Kasturiratne A, Ediriweera DS, de Silva HJ, Diggle P, Lalloo DG, Murray KA, Iwamura T. Integrating human behavior and snake ecology with agent-based models to predict snakebite in high risk landscapes. PLoS Negl Trop Dis 2021; 15:e0009047. [PMID: 33481802 PMCID: PMC7857561 DOI: 10.1371/journal.pntd.0009047] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/03/2021] [Accepted: 12/07/2020] [Indexed: 11/23/2022] Open
Abstract
Snakebite causes more than 1.8 million envenoming cases annually and is a major cause of death in the tropics especially for poor farmers. While both social and ecological factors influence the chance encounter between snakes and people, the spatio-temporal processes underlying snakebites remain poorly explored. Previous research has focused on statistical correlates between snakebites and ecological, sociological, or environmental factors, but the human and snake behavioral patterns that drive the spatio-temporal process have not yet been integrated into a single model. Here we use a bottom-up simulation approach using agent-based modelling (ABM) parameterized with datasets from Sri Lanka, a snakebite hotspot, to characterise the mechanisms of snakebite and identify risk factors. Spatio-temporal dynamics of snakebite risks are examined through the model incorporating six snake species and three farmer types (rice, tea, and rubber). We find that snakebites are mainly climatically driven, but the risks also depend on farmer types due to working schedules as well as species present in landscapes. Snake species are differentiated by both distribution and by habitat preference, and farmers are differentiated by working patterns that are climatically driven, and the combination of these factors leads to unique encounter rates for different landcover types as well as locations. Validation using epidemiological studies demonstrated that our model can explain observed patterns, including temporal patterns of snakebite incidence, and relative contribution of bites by each snake species. Our predictions can be used to generate hypotheses and inform future studies and decision makers. Additionally, our model is transferable to other locations with high snakebite burden as well.
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Affiliation(s)
- Eyal Goldstein
- School of Zoology, Department of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Joseph J. Erinjery
- School of Zoology, Department of Life Sciences, Tel Aviv University, Tel Aviv, Israel
- Department of Zoology, Kannur University, Kannur, India
| | - Gerardo Martin
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- Grantham Institute—Climate Change and Environment, Imperial College London, London, United Kingdom
| | - Anuradhani Kasturiratne
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | | | | | - Peter Diggle
- CHICAS, Lancaster University Medical School, Lancaster, United Kingdom
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Kris A. Murray
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- Grantham Institute—Climate Change and Environment, Imperial College London, London, United Kingdom
- MRC Unit the Gambia at London School of Hygiene and Tropical Medicine, Atlantic boulevard, Fajara, The Gambia
| | - Takuya Iwamura
- School of Zoology, Department of Life Sciences, Tel Aviv University, Tel Aviv, Israel
- Department of Forest Ecosystems and Society, College of Forestry, Oregon State University, Corvallis, Oregon, United States of America
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Ashton PM, Thanh LT, Trieu PH, Van Anh D, Trinh NM, Beardsley J, Kibengo F, Chierakul W, Dance DAB, Rattanavong S, Davong V, Hung LQ, Chau NVV, Tung NLN, Chan AK, Thwaites GE, Lalloo DG, Anscombe C, Nhat LTH, Perfect J, Dougan G, Baker S, Harris S, Day JN. Three phylogenetic groups have driven the recent population expansion of Cryptococcus neoformans. Nat Commun 2019; 10:2035. [PMID: 31048698 PMCID: PMC6497710 DOI: 10.1038/s41467-019-10092-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/15/2019] [Indexed: 01/04/2023] Open
Abstract
Cryptococcus neoformans (C. neoformans var. grubii) is an environmentally acquired pathogen causing 181,000 HIV-associated deaths each year. We sequenced 699 isolates, primarily C. neoformans from HIV-infected patients, from 5 countries in Asia and Africa. The phylogeny of C. neoformans reveals a recent exponential population expansion, consistent with the increase in the number of susceptible hosts. In our study population, this expansion has been driven by three sub-clades of the C. neoformans VNIa lineage; VNIa-4, VNIa-5 and VNIa-93. These three sub-clades account for 91% of clinical isolates sequenced in our study. Combining the genome data with clinical information, we find that the VNIa-93 sub-clade, the most common sub-clade in Uganda and Malawi, was associated with better outcomes than VNIa-4 and VNIa-5, which predominate in Southeast Asia. This study lays the foundation for further work investigating the dominance of VNIa-4, VNIa-5 and VNIa-93 and the association between lineage and clinical phenotype.
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Affiliation(s)
- P M Ashton
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T Thanh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - P H Trieu
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - D Van Anh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - N M Trinh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Beardsley
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Marie Bashir Institute, University of Sydney, Sydney, 2050, NSW, Australia
| | - F Kibengo
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - W Chierakul
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - D A B Dance
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - S Rattanavong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - V Davong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - L Q Hung
- Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - N V V Chau
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - N L N Tung
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - A K Chan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, M4N 3M5, ON, Canada
- Dignitas International, Zomba, Malawi
| | - G E Thwaites
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - D G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - C Anscombe
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T H Nhat
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Perfect
- Department of Medicine and Department of Molecular Genetics and Microbiology, Division of Infectious Diseases, Duke University, Durham, NC, 27710, USA
| | - G Dougan
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Baker
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Harris
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
| | - J N Day
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam.
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK.
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Ediriweera DS, Diggle PJ, Kasturiratne A, Pathmeswaran A, Gunawardena NK, Jayamanne SF, Isbister GK, Dawson A, Lalloo DG, de Silva HJ. Evaluating temporal patterns of snakebite in Sri Lanka: the potential for higher snakebite burdens with climate change. Int J Epidemiol 2018; 47:2049-2058. [PMID: 30215727 PMCID: PMC6280932 DOI: 10.1093/ije/dyy188] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 11/14/2022] Open
Abstract
Background Snakebite is a neglected tropical disease that has been overlooked by healthcare decision makers in many countries. Previous studies have reported seasonal variation in hospital admission rates due to snakebites in endemic countries including Sri Lanka, but seasonal patterns have not been investigated in detail. Methods A national community-based survey was conducted during the period of August 2012 to June 2013. The survey used a multistage cluster design, sampled 165 665 individuals living in 44 136 households and recorded all recalled snakebite events that had occurred during the preceding year. Log-linear models were fitted to describe the expected number of snakebites occurring in each month, taking into account seasonal trends and weather conditions, and addressing the effects of variation in survey effort during the study and of recall bias amongst survey respondents. Results Snakebite events showed a clear seasonal variation. Typically, snakebite incidence is highest during November-December followed by March-May and August, but this can vary between years due to variations in relative humidity, which is also a risk factor. Low relative-humidity levels are associated with high snakebite incidence. If current climate-change projections are correct, this could lead to an increase in the annual snakebite burden of 31.3% (95% confidence interval: 10.7-55.7) during the next 25-50 years. Conclusions Snakebite in Sri Lanka shows seasonal variation. Additionally, more snakebites can be expected during periods of lower-than-expected humidity. Global climate change is likely to increase the incidence of snakebite in Sri Lanka.
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Affiliation(s)
- Dileepa Senajith Ediriweera
- Centre for Health Informatics, Biostatistics and Epidemiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
- Centre for Health Informatics, Computing and Statistics, Lancaster University Medical School, Lancaster, UK
| | - Peter John Diggle
- Centre for Health Informatics, Computing and Statistics, Lancaster University Medical School, Lancaster, UK
| | | | | | | | | | - Geoffrey Kennedy Isbister
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Waratah, Australia
| | - Andrew Dawson
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Addiction Medicine, Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David Griffith Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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6
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Graham SM, Harrison WJ, Lalloo DG, Simpson AH, Laubscher M, Held M, Ferreira N, Maqungo S. HOST Study — HIV in Orthopaedic Skeletal Trauma Study: protocol for a multicentre case-cohort study. SA orthop j 2018. [DOI: 10.17159/2309-8309/2018/v17n3a7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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7
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Ediriweera DS, Kasturiratne A, Pathmeswaran A, Gunawardena NK, Wijayawickrama BA, Jayamanne SF, Isbister GK, Dawson A, Giorgi E, Diggle PJ, Lalloo DG, de Silva HJ. Mapping the Risk of Snakebite in Sri Lanka - A National Survey with Geospatial Analysis. PLoS Negl Trop Dis 2016; 10:e0004813. [PMID: 27391023 PMCID: PMC4938527 DOI: 10.1371/journal.pntd.0004813] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 06/08/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There is a paucity of robust epidemiological data on snakebite, and data available from hospitals and localized or time-limited surveys have major limitations. No study has investigated the incidence of snakebite across a whole country. We undertook a community-based national survey and model based geostatistics to determine incidence, envenoming, mortality and geographical pattern of snakebite in Sri Lanka. METHODOLOGY/PRINCIPAL FINDINGS The survey was designed to sample a population distributed equally among the nine provinces of the country. The number of data collection clusters was divided among districts in proportion to their population. Within districts clusters were randomly selected. Population based incidence of snakebite and significant envenoming were estimated. Model-based geostatistics was used to develop snakebite risk maps for Sri Lanka. 1118 of the total of 14022 GN divisions with a population of 165665 (0.8%of the country's population) were surveyed. The crude overall community incidence of snakebite, envenoming and mortality were 398 (95% CI: 356-441), 151 (130-173) and 2.3 (0.2-4.4) per 100000 population, respectively. Risk maps showed wide variation in incidence within the country, and snakebite hotspots and cold spots were determined by considering the probability of exceeding the national incidence. CONCLUSIONS/SIGNIFICANCE This study provides community based incidence rates of snakebite and envenoming for Sri Lanka. The within-country spatial variation of bites can inform healthcare decision making and highlights the limitations associated with estimates of incidence from hospital data or localized surveys. Our methods are replicable, and these models can be adapted to other geographic regions after re-estimating spatial covariance parameters for the particular region.
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Affiliation(s)
| | | | | | | | | | | | - Geoffrey Kennedy Isbister
- Clinical Toxicology Research Group, University of Newcastle, Waratah, Australia
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew Dawson
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
- Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Emanuele Giorgi
- CHICAS, Lancaster University Medical School, Lancaster, United Kingdom
| | - Peter John Diggle
- CHICAS, Lancaster University Medical School, Lancaster, United Kingdom
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8
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Benjamin LA, Kelly M, Cohen D, Neuhann F, Galbraith S, Mallewa M, Hopkins M, Hart IJ, Guiver M, Lalloo DG, Heyderman RS, Solomon T. Detection of herpes viruses in the cerebrospinal fluid of adults with suspected viral meningitis in Malawi. Infection 2013; 41:27-31. [PMID: 22798048 PMCID: PMC3566386 DOI: 10.1007/s15010-012-0292-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 06/25/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE We looked for herpes simplex virus types 1 and 2 (HSV-1 and HSV-2, respectively), varicella zoster virus (VZV), Epstein-Barr virus (EBV) and cytomegalovirus (CMV) DNA in Malawian adults with clinically suspected meningitis. METHODS We collected cerebrospinal fluid (CSF) from consecutive adults admitted with clinically suspected meningitis to Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi, for a period of 3 months. Those with proven bacterial or fungal meningitis were excluded. Real-time polymerase chain reaction (PCR) was performed on the CSF for HSV-1 and HSV-2, VZV, EBV and CMV DNA. RESULTS A total of 183 patients presented with clinically suspected meningitis. Of these, 59 (32 %) had proven meningitis (bacterial, tuberculous or cryptococcal), 39 (21 %) had normal CSF and 14 (8 %) had aseptic meningitis. For the latter group, a herpes virus was detected in 9 (64 %): 7 (50 %) had EBV and 2 (14 %) had CMV, all were human immunodeficiency virus (HIV)-positive. HSV-2 and VZV were not detected. Amongst those with a normal CSF, 8 (21 %) had a detectable herpes virus, of which 7 (88 %) were HIV-positive. CONCLUSIONS The spectrum of causes of herpes viral meningitis in this African population is different to that in Western industrialised settings, with EBV being frequently detected in the CSF. The significance of this needs further investigation.
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Affiliation(s)
- L A Benjamin
- Brain Infections Group, Walton Centre NHS Foundation Trust, and Institute of Infection and Global Health, University of Liverpool, The Apex Building, 8 West Derby Street, Liverpool, L69 7BE, UK.
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9
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Gautret P, Cramer JP, Field V, Caumes E, Jensenius M, Gkrania-Klotsas E, de Vries PJ, Grobusch MP, Lopez-Velez R, Castelli F, Schlagenhauf P, Hervius Askling H, von Sonnenburg F, Lalloo DG, Loutan L, Rapp C, Basto F, Santos O’Connor F, Weld L, Parola P, for the EuroTravNet Network. Infectious diseases among travellers and migrants in Europe, EuroTravNet 2010. Euro Surveill 2012. [DOI: 10.2807/ese.17.26.20205-en] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To investigate trends in travel-associated morbidity with particular emphasis on emerging infections with the potential for introduction into Europe, diagnoses of 7,408 returning travellers presenting to 16 EuroTravNet sites in 2010 were compared with 2008 and 2009. A significant increase in reported Plasmodium falciparum malaria (n=393 (6% of all travel-related morbidity) vs. n=267 (4%) and 296 (5%); p<0.001), P. vivax malaria (n=53 (1%) vs. n=31 (0.5%) and 39 (1%); p=0.038) and dengue fever (n=327 (5%) vs. n=131 (2%) and 172 (2%); p<0.001) was observed. Giardia lamblia was identified in 16% of patients with acute diarrhoea, with no significant annual variation. The proportion of acute diarrhoea due to Campylobacter increased from 7% in 2008 to 12% in 2010 (p=0.002). We recorded 121 patients with pulmonary tuberculosis in 2010, a three-fold increase in the proportionate morbidity from 2008 to 2010. In 2010, 60 (0.8%) cases of chronic Chagas disease, 151 (2%) cases of schistosomiasis and 112 (2%) cases of cutaneous larva migrans were reported. Illness patterns in sentinel travellers, captured by EuroTravnet, continue to highlight the potential role of travellers in the emergence of infectious diseases of public health concern in Europe and the relevance of offering medical travel advice and enforcing specific and adequate prophylaxis.*
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Affiliation(s)
- P Gautret
- University Hospital Institute for Infectious and Tropical Diseases, Marseille, France
| | - J P Cramer
- University Medical Center Hamburg-Eppendorf, Department of Tropical Medicine and Infectious Diseases, Bernhard Nocht Clinic, Hamburg, Germany
| | - V Field
- InterHealth and National Travel Health Network and Centre (NaTHNaC), London, United Kingdom
| | - E Caumes
- Service des Maladies Infectieuses et Tropicales (Department of Infectious and Tropical Diseases), Hôpital Pitié-Salpétrière, Paris, France
| | - M Jensenius
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - E Gkrania-Klotsas
- Department of Infectious Diseases, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - P J de Vries
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Center, Amsterdam, the Netherlands
| | - M P Grobusch
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Center, Amsterdam, the Netherlands
| | - R Lopez-Velez
- Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramón y Cajal Hospital, Madrid, Spain
| | - F Castelli
- University Division of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, Brescia, Italy
| | - P Schlagenhauf
- Centre for Travel Medicine, University of Zürich, Zürich, Switzerland
| | - H Hervius Askling
- Department of Medicine/Solna, Unit for Infectious Diseases, Karolinska Institute, Stockholm, Sweden
| | - F von Sonnenburg
- Department of Infectious Diseases and Tropical Medicine, Ludwig-Maximilian’s University of Munich, Munich, Germany
| | - D G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - L Loutan
- Division of International and Humanitarian Health, Geneva University Hospitals, Geneva, Switzerland
| | - C Rapp
- Department of Infectious and Tropical Diseases, Bégin Military Hospital, Saint-Mandé, France
| | - F Basto
- Centro Hospitalar São João (Hospital Centre São João), International Health Unit, Porto, Portugal
| | - F Santos O’Connor
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - L Weld
- ISTM/Geosentinel Statistician Consultant, Victoria, Canada
| | - P Parola
- University Hospital Institute for Infectious and Tropical Diseases, Marseille, France
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10
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Gautret P, Cramer JP, Field V, Caumes E, Jensenius M, Gkrania-Klotsas E, de Vries PJ, Grobusch MP, Lopez-Velez R, Castelli F, Schlagenhauf P, Hervius Askling H, von Sonnenburg F, Lalloo DG, Loutan L, Rapp C, Basto F, Santos O'Connor F, Weld L, Parola P. Infectious diseases among travellers and migrants in Europe, EuroTravNet 2010. Euro Surveill 2012; 17:20205. [PMID: 22790534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
To investigate trends in travel-associated morbidity with particular emphasis on emerging infections with the potential for introduction into Europe, diagnoses of 7,408 returning travellers presenting to 16 EuroTravNet sites in 2010 were compared with 2008 and 2009. A significant increase in reported Plasmodium falciparum malaria (n=361 (6% of all travel-related morbidity) vs. n=254 (4%) and 260 (5%); p<0.001), P. vivax malaria (n=51 (1%) vs. n=31 (0.5%) and 38 (1%); p=0.027) and dengue fever (n=299 (5%) vs. n=127 (2%) and 127 (2%); p<0.001) was observed. Giardia lamblia was identified in 16% of patients with acute diarrhoea, with no significant annual variation. The proportion of acute diarrhoea due to Campylobacter increased from 7% in 2008 to 12% in 2010 (p=0.001). We recorded 121 patients with pulmonary tuberculosis in 2010, a threefold increase in the proportionate morbidity from 2008 to 2010. In 2010, 60 (0.8%) cases of chronic Chagas disease, 151 (2%) cases of schistosomiasis and 112 (2%) cases of cutaneous larva migrans were reported. Illness patterns in sentinel travellers, captured by EuroTravnet, continue to highlight the potential role of travellers in the emergence of infectious diseases of public health concern in Europe and the relevance of offering medical travel advice and enforcing specific and adequate prophylaxis.
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Affiliation(s)
- P Gautret
- University Hospital Institute for Infectious and Tropical Diseases, Marseille, France
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11
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Dickinson L, Chaponda M, Carr D, van Oosterhout JJ, Kumwenda J, Lalloo DG, Pirmohamed M, Heyderman R, Khoo SH. Population pharmacokinetic and pharmacogenetic analysis of nevirapine in hypersensitive and tolerant HIV-infected patients from Malawi. J Int AIDS Soc 2010. [PMCID: PMC3112962 DOI: 10.1186/1758-2652-13-s4-p181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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12
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Namakoola I, Wakeham K, Parkes-Ratanshi R, Levin J, Mugagga T, Seymour C, Kissa J, Kamali A, Lalloo DG. Use of nail and oral pigmentation to determine ART eligibility among HIV-infected Ugandan adults. Trop Med Int Health 2010; 15:259-62. [PMID: 20409288 DOI: 10.1111/j.1365-3156.2009.02448.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the use of grey/distal banded nails as an indicator of advanced immunosuppression, and thus eligibility for ART, in resource poor settings. METHODS We tested whether grey/distal banded nails and/or oral pigmentation could be used to identify patients with low CD4 cell counts at two cut-offs: <200 and <350 cells/microl in ART naive adults. RESULTS Four hundred and three nail and oral cavities were photographed and assessed. Grey/distal banded nails and/or oral pigmentation were significantly associated with a CD4 cell count <200 cells/microl (P < 0.001), with a sensitivity of 66%, a specificity of 50% and a negative predictive value of 77%. However, there was no association when a CD4 cell count cut-off of <350 cells/microl was used. Inter-observer agreement (k 0.46) was fair/moderate. CONCLUSIONS While grey/distal banded nails and/or oral pigmentation are associated with low CD4 counts, the sensitivity and kappa score are too low for this method to be recommended as a tool to guide ART initiation; large number of individuals eligible for ART would be missed.
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Affiliation(s)
- I Namakoola
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
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13
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Bell DJ, Wijegunasinghe D, Samarakoon S, Palipana H, Gunasekera S, de Silva HA, Lalloo DG, Ranawaka UK, de Silva HJ. Neurophysiological findings in patients 1 year after snake bite induced neurotoxicity in Sri Lanka. Trans R Soc Trop Med Hyg 2010; 104:351-6. [PMID: 20096908 DOI: 10.1016/j.trstmh.2009.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 12/10/2009] [Accepted: 12/10/2009] [Indexed: 10/19/2022] Open
Abstract
Snake bite causes significant morbidity and mortality in Sri Lanka. Snake venoms contain neurotoxins that block neuromuscular junction transmission. Presynaptic neurotoxicity most commonly causes destruction of nerve terminals with recovery by regrowth, whilst postsynaptic neurotoxicity usually involves competition at the acetylcholine receptor. The aim of this study was to investigate whether there were long-term clinical or neurophysiological changes in snake bite survivors 1 year after their envenoming. Detailed neurophysiological tests and clinical examinations were performed on 26 snake bite victims who had presented with neurotoxicity 12 months previously, and their results were compared with controls recruited from the same communities. Significant differences were observed in some nerve conduction parameters in some snake bite victims compared with controls, predominantly in those thought to have elapid bites, including prolongation of sensory, motor and F-wave latencies and reduction of conduction velocities. There was no evidence of any residual deficits in neuromuscular junction transmission. These results suggest a possible demyelinating type polyneuropathy. None of the cases or controls had abnormalities on clinical examination. This is one of the few studies to report possible long-term neurological damage following systemic neurotoxicity after snake bite. The clinical significance of these neurophysiological abnormalities is uncertain and further studies are required to investigate whether the abnormalities persist and to see whether clinical consequences develop.
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Affiliation(s)
- D J Bell
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK.
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14
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Abstract
BACKGROUND Severe malaria kills over a million people every year. We sought evidence of superiority of artesunate compared with the standard treatment quinine. OBJECTIVES To compare artesunate with quinine for treating severe malaria. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (January 2007), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to January 2007), EMBASE (1974 to January 2007), LILACS (1982 to January 2007), ISI Web of Science (1945 to January 2007), the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles. We contacted researchers and the World Health Organization. SELECTION CRITERIA Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth. DATA COLLECTION AND ANALYSIS Two authors assessed the eligibility and methodological quality of trials, extracted and analysed data, and drafted the review. The third author contributed to the design and writing of the review. Death was the primary outcome. Dichotomous outcomes were summarized using relative risks and continuous outcomes by mean differences. Where appropriate, we combined data in meta-analyses. Heterogeneity was investigated for the primary outcome using subgroup analyses. MAIN RESULTS Six trials enrolling 1938 participants (1664 adults and 274 children) met our inclusion criteria. All six trials were conducted in Asia, and only one small trial enrolled only children. Five trials used intravenous artesunate and one trial intramuscular artesunate; all six used intravenous quinine. Treatment with artesunate significantly reduced the risk of death (RR 0.62, 95% CI 0.51 to 0.75; 1938 participants, 6 trials), reduced parasite clearance time (WMD 8.14 h, 95% CI 11.55 to 4.73; 292 participants, 3 trials), and hypoglycaemia detected by routine monitoring (RR 0.46, 95% CI 0.25 to 0.87; 185 participants, 2 trials). There was no evidence of a difference in neurological sequelae, coma recovery time, time to hospital discharge, fever clearance time, or adverse effects other than hypoglycaemia. AUTHORS' CONCLUSIONS Intravenous artesunate is the drug of choice for adults with severe malaria, particularly if acquired in Asia. This review did not identify sufficient data to make firm conclusions about the treatment of children or the effectiveness of intramuscular artesunate. There is an urgent need to compare the effects of artesunate with quinine in African children with severe malaria. The applicability of these results to Asian children and the ethics of further research are points of debate.
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Affiliation(s)
- K L Jones
- Liverpool School of Tropical Medicine, International Health Group, Pembroke Place, Liverpool, Merseyside, UK, L3 5QA.
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15
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Pathmeswaran A, Kasturiratne A, Fonseka M, Nandasena S, Lalloo DG, de Silva HJ. Identifying the biting species in snakebite by clinical features: an epidemiological tool for community surveys. Trans R Soc Trop Med Hyg 2006; 100:874-8. [PMID: 16412486 DOI: 10.1016/j.trstmh.2005.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Revised: 09/26/2005] [Accepted: 10/03/2005] [Indexed: 11/24/2022] Open
Abstract
The outcome of snakebite is related to the biting species but it is often difficult to identify the biting snake, particularly in community settings. We have developed a clinical scoring system suitable for use in epidemiological surveys, with the main aim of identifying the presumed biting species in those with systemic envenoming who require treatment. The score took into account ten features relating to bites of the five medically important snakes in Sri Lanka, and an algorithm was developed applying different weightings for each feature for different species. A systematically developed artificial data set was used to fine tune the score and to develop criteria for definitive identification. The score was prospectively validated using 134 species-confirmed snakebites. It correctly differentiated the bites caused by the three snakes that commonly cause major clinical problems (Russell's viper (RV), kraits and cobra) from other snakes (hump-nosed viper (HNV) and saw-scaled viper (SSV)) with 80% sensitivity and 100% specificity. For individual species, sensitivity and specificity were, respectively: cobra 76%, 99%; kraits 85%, 99%; and RV 70%, 99%. As anticipated, the score was insensitive in the identification of bites due to HNV and SSV.
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Affiliation(s)
- A Pathmeswaran
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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16
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Fox S, Rathuwithana AC, Kasturiratne A, Lalloo DG, de Silva HJ. Underestimation of snakebite mortality by hospital statistics in the Monaragala District of Sri Lanka. Trans R Soc Trop Med Hyg 2006; 100:693-5. [PMID: 16289649 DOI: 10.1016/j.trstmh.2005.09.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Revised: 09/01/2005] [Accepted: 09/05/2005] [Indexed: 11/13/2022] Open
Abstract
Estimates of snakebite mortality are mostly based on hospital data, although these may considerably underestimate the problem. In order to determine the accuracy of hospital-based statistics, data on snakebite mortality in all hospitals in the Monaragala District of Sri Lanka were compared to data on snakebite as the certified cause of death for the district, for the 5-year period between 1999 and 2003. Data were cross-checked in a sample of hospitals and divisional secretariats within the district. Hospital statistics did not report 45 (62.5%) of the true number of snakebite deaths in the Monaragala District. Twenty-six (36.1%) of the victims either did not seek, or had no access to, a hospital. Another 19 (26.4%) had arrived at hospital, but had done so too late to receive treatment. Our study confirms the limitations of official hospital-based mortality data on snakebite.
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Affiliation(s)
- S Fox
- Liverpool School of Tropical Medicine, Liverpool, UK
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17
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Kasturiratne A, Pathmeswaran A, Fonseka MMD, Lalloo DG, Brooker S, de Silva HJ. Estimates of disease burden due to land-snake bite in Sri Lankan hospitals. Southeast Asian J Trop Med Public Health 2005; 36:733-40. [PMID: 16124448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Snake bite is a common cause of hospital admission in Sri Lanka. Despite this, there have been no countrywide studies or national estimates of disease burden due to snake bites in Sri Lankan hospitals. We assessed the disease burden due to snake bite in our hospitals and estimated the frequency of admissions due to bites by different snake species. Sri Lanka was divided into four zones based on climate and topography. Hospital morbidity and mortality data, which are available on an administrative district basis, were collated for the four zones. A survey of opinion among specialist physicians (the Delphi technique) was used to estimate the proportion of bites by different species, and requirements for anti-venom (AV) and intensive care facilities for management of snake bites in hospitals in each of the four zones. A study of hospital admissions due to snake bites in seven selected hospitals was also performed to validate the opinion survey. There was a clear difference in the incidence of hospital admissions due to snake bites in the different zones. Estimates of hospital admissions due to bites by different species also varied considerably between zones. These trends corresponded to estimates of requirements of AV and other supportive health care. Health care planning using data based on environmental information, rather than merely on political boundaries, could lead to targeted distribution of AV and intensive care requirements to manage snake bites.
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Affiliation(s)
- A Kasturiratne
- Department of Community and Family Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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18
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Affiliation(s)
- J N Day
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Ho Chi Minh City, VietNam.
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19
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de Silva HA, Fonseka MMD, Pathmeswaran A, Alahakone DGS, Ratnatilake GA, Gunatilake SB, Ranasinha CD, Lalloo DG, Aronson JK, de Silva HJ. Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial. Lancet 2003; 361:1935-8. [PMID: 12801736 DOI: 10.1016/s0140-6736(03)13581-7] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Deliberate self-poisoning with yellow oleander seeds is common in Sri Lanka and is associated with severe cardiac toxicity and a mortality rate of about 10%. Specialised treatment with antidigoxin Fab fragments and temporary cardiac pacing is expensive and not widely available. Multiple-dose activated charcoal binds cardiac glycosides in the gut lumen and promotes their elimination. We aimed to assess the efficacy of multiple-dose activated charcoal in the treatment of patients with yellow-oleander poisoning. METHODS On admission, participants received one dose of activated charcoal and were then randomly assigned either 50 g of activated charcoal every 6 h for 3 days or sterile water as placebo. A standard treatment protocol was used in all patients. We monitored cardiac rhythm and did 12-lead electocardiographs as needed. Death was the primary endpoint, and secondary endpoints were life-threatening cardiac arrhythmias, dose of atropine used, need for cardiac pacing, admission to intensive care, and number of days in hospital. Analysis was by intention to treat. FINDINGS 201 patients received multiple-dose activated charcoal and 200 placebo. There were fewer deaths in the treatment group (five [2.5%] vs 16 [8%]; percentage difference 5.5%; 95% CI 0.6-10.3; p=0.025), and we noted difference in favour of the treatment group for all secondary endpoints, apart from number of days in hospital. The drug was safe and well tolerated. INTERPRETATION Multiple-dose activated charcoal is effective in reducing deaths and life-threatening cardiac arrhythmias after yellow oleander poisoning and should be considered in all patients. Use of activated charcoal could reduce the cost of treatment.
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Affiliation(s)
- H A de Silva
- Faculty of Medicine, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
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20
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Abstract
Pericarditis, usually viral in origin, is an infrequent cause of chest pain. Pericarditis due to drug allergy is even less frequent and is thus rarely considered in the differential diagnosis. A case is reported of a woman who presented with severe chest pain, caused by minocycline induced pericarditis. Such allergy may be more common than reported. It is suggested that drug induced pericarditis should be included in the differential diagnosis of acute chest pain.
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Affiliation(s)
- P Davey
- Nuffield Department of Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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21
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Seaton RA, Trevett AJ, Wembri JP, Nwokolo N, Naraqi S, Black J, Laurenson IF, Kevau I, Saweri A, Lalloo DG, Warrell DA. Randomized comparison of intramuscular artemether and intravenous quinine in adult, Melanesian patients with severe or complicated, Plasmodium falciparum malaria in Papua New Guinea. Ann Trop Med Parasitol 1998; 92:133-9. [PMID: 9625908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
An open-label, randomized, controlled trial was used to compare the safety and efficacy of intramuscular artemether (a loading dose of 3.2 mg/kg, followed by 1.6 mg/kg daily for 4 days) and intravenous quinine (a loading dose of 20 mg quinine dihydrochloride/kg, followed first by 10 mg/kg every 8 h, each injection taking 4 h, for at least 48 h, and then oral quinine for a total of 7 days) in the management of strictly defined severe/complicated malaria in Melanesian adults. Four (12%) of the 33 patients who enrolled and completed follow-up died (one of the 15 who received artemether and three of the 18 who received quinine). Overall, cerebral malaria was uncommon (6%) whilst jaundice was common (76%). The time taken to clear 50% of parasites was less in those treated with artemether (median = 8 h; range = 2-24 h) than in the patients given quinine (median = 14 h; range = 2-25 h; P = 0.05). Temperature defervescence was also quicker in those treated with artemether (median = 32 hours; range = 20-112 h) than in those in the quinine group (median = 48 h; range = 28-88 h; P = 0.034). Hypoglycaemia was not observed in any patient treated with artemether but complicated therapy in 11 (79%) of the 14 patients given quinine who had not had pre-treatment spontaneous hypoglycaemia. No serious adverse effects were attributable to artemether. The Plasmodium falciparum infections observed during the 1 month of follow-up, in three patients who had received artemether and two who had been given quinine, were probably due to recrudescence. Plasmodium vivax parasitaemias were also observed during follow-up, in one or two patients in each treatment group. Artemether appears safe in Melanesian adults and is probably as effective as intravenous quinine in the treatment of severe or complicated falciparum malaria.
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Affiliation(s)
- R A Seaton
- Department of Clinical Sciences, University of Papua New Guinea, Port Moresby, Papua, New Guinea.
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22
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Laurenson IF, Lalloo DG, Naraqi S, Seaton RA, Trevett AJ, Matuka A, Kevau IH. Cryptococcus neoformans in Papua New Guinea: a common pathogen but an elusive source. J Med Vet Mycol 1997; 35:437-40. [PMID: 9467113 DOI: 10.1080/02681219780001561] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Around Port Moresby, Papua New Guinea (PNG), the annual incidence of cryptococcal meningitis is estimated to be up to 42.8 per million population; Cryptococcus neoformans var. gattii is the predominant causative agent. In Australia and California, environmental isolations have established an ecological association of C. neoformans var. gattii with Eucalyptus camaldulensis, E. tereticornis, and more recently E. rudis and E. gomphcephala. In PNG few E. camaldulensis survive experimental planting, E. tereticornis is endemic and there are no records of planting of the non-endemic E. rudis and E. gomphcephela. Despite extensive sampling of eucalypt-associated and other sources, we were unable to identify the ecological niche of C. neoformans var. gattii and neoformans in this region.
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Affiliation(s)
- I F Laurenson
- Department of Clinical Sciences, University of Papua New Guinea, Boroko, Papua New Guinea.
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23
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Lalloo DG, Trevett AJ, Warrell DA. Severe envenomation by the taipan (Oxyuranus scutellatus). Med J Aust 1997; 167:54-5. [PMID: 9236765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Conlon CP, Kayley J, Lalloo DG, Berendt AR. Intravenous antibiotic treatment at home can provide higher quality care. BMJ 1997; 314:1551. [PMID: 9183213 PMCID: PMC2126789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Goulder PJ, Sewell AK, Lalloo DG, Price DA, Whelan JA, Evans J, Taylor GP, Luzzi G, Giangrande P, Phillips RE, McMichael AJ. Patterns of immunodominance in HIV-1-specific cytotoxic T lymphocyte responses in two human histocompatibility leukocyte antigens (HLA)-identical siblings with HLA-A*0201 are influenced by epitope mutation. J Exp Med 1997; 185:1423-33. [PMID: 9126923 PMCID: PMC2196285 DOI: 10.1084/jem.185.8.1423] [Citation(s) in RCA: 159] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/1996] [Revised: 02/14/1997] [Indexed: 02/04/2023] Open
Abstract
Primary human immunodeficiency virus (HIV) infection is controlled principally by HIV-specific cytotoxic T lymphocytes (CTL) to a steady-state level of virus load, which strongly influences the ultimate rate of progression to disease. Epitope selection by CTL may be an important determinant of the degree of immune control over the virus. This report describes the CTL responses of two HLA-identical hemophiliac brothers who were exposed to identical batches of Factor VIII and became seropositive within 10 wk of one another. Both have HLA-A*0201. The CTL responses of the two siblings were very dissimilar, one donor making strong responses to two epitopes within p17 Gag (HLA-A*0201-restricted SLYNTVATL and HLA-A3-restricted RLRPGGKKK). The sibling responded to neither epitope, but made strong responses to two epitopes presented by HLA-B7. This was not the result of differences in presentation of the epitopes. However, mutations in both immunodominant epitopes of the p17 Gag responder were seen in proviral sequences of the nonresponder. We then documented the CTL responses to two HLA-A*0201-restricted epitopes, in Gag (SLYNTVATL) and Pol (ILKEPVHGV) in 22 other HIV-infected donors with HLA-A*0201. The majority (71%) generated responses to the Gag epitope. In the 29% of donors failing to respond to the Gag epitope in standard assays, there was evidence of low frequency memory CTL responses using peptide stimulation of PBMC, and most of these donors also showed mutations in or around the Gag epitope. We concluded that HLA class I genotype determines epitope selection initially but that mutation in immunodominant epitopes can profoundly alter the pattern of CTL response.
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Affiliation(s)
- P J Goulder
- Nuffield Department of Medicine, Institute of Molecular Medicine, John Radcliffe Hospital, Headington, Oxford, United Kingdom
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26
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Lalloo DG, Trevett AJ, Nwokolo N, Laurenson IF, Naraqi S, Kevau I, Kemp MW, James R, Hooper L, David R, Theakston G, Warrell D. Electrocardiographic abnormalities in patients bitten by taipans (Oxyuranus scutellatus canni) and other elapid snakes in Papua New Guinea. Trans R Soc Trop Med Hyg 1997; 91:53-6. [PMID: 9093629 DOI: 10.1016/s0035-9203(97)90394-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Envenoming by a number of species of snake may affect the myocardium or cause electrocardiographic changes; several different mechanisms have been proposed. In a prospective study of snake bite in Papua New Guinea, electrocardiographic changes were observed in 36 of 69 patients (52%) envenomed by the taipan (Oxyuranus scutellatus), 2 of 6 (33%) envenomed by death adders (Acanthophis sp.) and one envenomed by the brown snake (Pseudonaja textilis). Septal T wave inversion and bradycardias, including atrioventricular block, were the commonest abnormalities. There was no haemodynamic deterioration. The cause of these changes is uncertain; only 2 of 24 patients (8.3%) with electrocardiographic changes had markedly elevated plasma concentrations of cardiac troponin T, a sensitive and specific marker of myocardial damage. This suggests that myocardial damage is uncommon following bites by these species. Electrocardiographic abnormalities are most likely to have been caused by a direct toxic effect of a venom component upon cardiac myocyte function; in taipan bites, taicatoxin, a calcium channel blocker, might be responsible.
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Affiliation(s)
- D G Lalloo
- Centre for Tropical Medicine, John Radcliffe Hospital, Oxford, UK
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27
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Fekade D, Knox K, Hussein K, Melka A, Lalloo DG, Coxon RE, Warrell DA. Prevention of Jarisch-Herxheimer reactions by treatment with antibodies against tumor necrosis factor alpha. N Engl J Med 1996; 335:311-5. [PMID: 8663853 DOI: 10.1056/nejm199608013350503] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In patients with louse-borne relapsing fever (Borrelia recurrentis infection), antimicrobial treatment is often followed by sudden fever, rigors, and persistent hypotension (Jarisch-Herxheimer reactions) that are associated with increases in plasma concentrations of tumor necrosis factor alpha (TNF-alpha), interleukin-6, and interleukin-8. We attempted to determine whether sheep polyclonal Fab antibody fragments against TNF-alpha (anti-TNF-alpha Fab) could suppress the Jarisch-Herxheimer reaction. METHODS We conducted a randomized, double-blind, placebo-controlled trial in 49 patients with proven louse-borne relapsing fever. Immediately before the intramuscular injection of penicillin, the patients received an intravenous infusion of either anti-TNF-alpha Fab or a control solution. RESULTS Ten of the 20 patients given anti-TNF-alpha Fab had Jarisch-Herxheimer reactions with rigors, as compared with 26 of the 29 control patients (P = 0.006). The controls had significantly greater mean maximal increases in temperature (1.5 vs. 0.8 degrees C, P < 0.001), pulse rate (31 vs. 13 per minute, P < 0.001), and systolic blood pressure (25 vs. 15 mm Hg, P < 0.003), as well as higher mean peak plasma concentrations of interleukin-6 (50 vs. 17 micrograms per liter) and interleukin-8 (2000 vs 205 ng per liter) (P < 0.001 for both comparisons). Levels of TNF-alpha were undetectable after treatment with anti-TNF-alpha Fab. CONCLUSIONS Pretreatment with sheep anti-TNF-alpha Fab suppresses Jarisch-Herxheimer reactions that occur after penicillin treatment for louse-borne relapsing fever, reduces the associated increases in plasma concentrations of interleukin-6 and interleukin-8, and may be useful in other forms of sepsis.
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Affiliation(s)
- D Fekade
- Department of Internal Medicine, Black Lion Hospital, Addis Ababa, Ethiopia
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28
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Lalloo DG, Trevett AJ, Paul M, Korinhona A, Laurenson IF, Mapao J, Nwokolo N, Danga-Christian B, Black J, Saweri A, Naraqi S, Warrell DA. Severe and complicated falciparum malaria in Melanesian adults in Papua New Guinea. Am J Trop Med Hyg 1996; 55:119-24. [PMID: 8780447 DOI: 10.4269/ajtmh.1996.55.119] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Severe falciparum malaria usually occurs in children, but also occurs in nonimmune migrants or partially immune adults in areas of unstable transmission. We have studied prospectively 70 adult patients with strictly defined severe malaria from the south coast of Papua New Guinea where malaria transmission is not intense. Only 19 (27.1%) were migrants from areas where malaria transmission does not occur; many other patients were periurban dwellers who had become infected after visits to their home villages. The most common clinical features were jaundice or hepatic dysfunction, impaired consciousness, renal failure, cerebral malaria, and anemia. Hypoglycemia was common following treatment with quinine. The overall case fatality rate was 18.6%; renal failure and cerebral malaria in particular were associated with a poor outcome. Reduction in mortality might be achieved by aggressive therapy of renal failure with earlier institution of dialysis; the use of preventive measures for immigrants or urban dwellers returning to high transmission areas might reduce the incidence of this dangerous disease.
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Affiliation(s)
- D G Lalloo
- Department of Clinical Sciences, Faculty of Medicine, University of Papua New Guinea, Boroko, Papua New Guinea
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29
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Warrell DA, Hudson BJ, Lalloo DG, Trevett AJ, Whitehead P, Bamler PR, Ranaivoson M, Wiyono A, Richie TL, Fryauff DJ, O'Shea MT, Richards AM, Theakston RD. The emerging syndrome of envenoming by the New Guinea small-eyed snake Micropechis ikaheka. QJM 1996; 89:523-30. [PMID: 8759493 DOI: 10.1093/qjmed/89.7.523] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The New Guinea small-eyed or ikaheka snake, Micropechis ikaheka, which occurs throughout New Guinea and some adjacent islands, is feared by the indigenes. The first proven human fatality was in the 1950s and this species has since been implicated in many other cases of severe and fatal envenoming. Reliable attribution of envenoming to this species in victims unable to capture or kill the snake recently became possible by the use of enzyme immunoassay. Eleven cases of proven envenoming by M. ikaheka, with two fatalities, were identified in Papua New Guinea and Irian Jaya. Five patients showed no clinical signs of envenoming. The other six patients showed symptoms typical of envenoming by other Australasian elapids: mild local swelling, local lymphadenopathy, neurotoxicity, generalized myalgia, spontaneous systemic bleeding, incoagulable blood and passage of dark urine (haemoglobinuria or myoglobinuria). Two patients developed hypotension and two died of respiratory paralysis 19 and 38 h after being bitten. In vitro studies indicate that the venom is rich in phospholipase A2, is indirectly haemolytic, anticoagulant and inhibits platelets, but is not procoagulant or fibrinolytic. It shows predominantly post-synaptic neurotoxic and myotoxic activity. Anecdotally, Commonwealth Serum Laboratories' (CSL) death adder antivenom has proved ineffective whereas CSL polyvalent antivenom may be beneficial. Anticholinesterase drugs might prove effective in improving neuromuscular transmission and should be tested in patients with neurotoxic envenoming.
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Affiliation(s)
- D A Warrell
- Centre for Tropical Medicine, University of Oxford, UK
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30
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Lalloo DG, Trevett AJ, Black J, Mapao J, Saweri A, Naraqi S, Owens D, Kamiguti AS, Hutton RA, Theakston RD, Warrell DA. Neurotoxicity, anticoagulant activity and evidence of rhabdomyolysis in patients bitten by death adders (Acanthophis sp.) in southern Papua New Guinea. QJM 1996; 89:25-35. [PMID: 8730340 DOI: 10.1093/oxfordjournals.qjmed.a030134] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Thirty-two patients with enzyme-immunoassay-proven death adder (Acanthophis sp.) bites were studied in Port Moresby, Papua New Guinea. Eighteen were envenomed; local signs were rare and none had incoagulable blood, but all except one had signs of neurotoxicity. Five (27.7%) envenomed patients required intubation and ventilation. One patient developed renal failure, previously undescribed following death adder bites. Laboratory investigations showed mild prolongation of prothrombin and partial thromboplastin times in some patients. In vitro studies showed that the venom contains anticoagulant activity, but does not cause fibrinogenolysis. In contrast to taipan envenoming, neurotoxicity did not progress after antivenom administration, and there was reversal of neurotoxicity, evident within 6 h, in three severely envenomed patients treated less than 12 h after the bite. One patient treated with antivenom and anticholinesterases had the most dramatic response to treatment; the optimum management of bites by this species may include prompt treatment with both antivenom and anticholinesterases in addition to effective first aid.
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Affiliation(s)
- D G Lalloo
- Department of Clinical Sciences, University of Papua New Guinea, Port Moresby
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31
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Laurenson IF, Trevett AJ, Lalloo DG, Nwokolo N, Naraqi S, Black J, Tefurani N, Saweri A, Mavo B, Igo J, Warrell DA. Meningitis caused by Cryptococcus neoformans var. gattii and var. neoformans in Papua New Guinea. Trans R Soc Trop Med Hyg 1996; 90:57-60. [PMID: 8730314 DOI: 10.1016/s0035-9203(96)90479-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Eleven cases of cryptococcal meningitis were diagnosed and biotyped from September 1991 to August 1992 in Papua New Guinea (PNG). Seven isolates were Cryptococcus neoformans var. gattii from paediatric and adult patients, one with diabetes mellitus and 4 were C. neoformans var. neoformans from adults, of whom 2 had human immunodeficiency virus type 1 (HIV-1) infection, and one each had tuberculosis and Plasmodium vivax malaria. Significant clinical findings were headache, fever, meningism, vomiting, photophobia, papilloedema and cranial nerve lesions. Five patients (45.5%) died; 3 of these were adults with var. gattii and 2 were men with both var. neoformans and HIV-1 infections. This prospective tropical study documents the emergence of C. neoformans var. neoformans in patients with HIV-1 infection in a country where previously var. gattii had predominated in the immunocompetent. There has been no earlier report of cryptococcosis in an HIV-1 seropositive patient in PNG. Despite presumed exposure to both varieties of C. neoformans, var. gattii infections had been most frequent. As HIV-1 spreads, the proportion of hosts infected with var. neoformans may rise. The course of meningitis caused by the 2 varieties of C. neoformans may differ, with mortality in the tropics remaining particularly high. In PNG the environmental source of C. neoformans remains elusive.
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Affiliation(s)
- I F Laurenson
- Department of Clinical Sciences, University of Papua New Guinea, Boroko
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32
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Connolly S, Trevett AJ, Nwokolo NC, Lalloo DG, Naraqi S, Mantle D, Schofield IS, Fawcett PR, Harris JB, Warrell DA. Neuromuscular effects of Papuan Taipan snake venom. Ann Neurol 1995; 38:916-20. [PMID: 8526464 DOI: 10.1002/ana.410380612] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Snakebite is a cause of significant morbidity in Central Province, Papua New Guinea. Three adult patients with clinical evidence of neurotoxicity following envenomation by the Papuan taipan had serial neurophysiological examinations over the course of their subsequent hospitalization. All required artificial ventilation for 2.5 to 5 days. The compound muscle action potential (CMAP) amplitudes declined over the first 2 to 4 days after envenoming and then gradually increased in parallel with clinical recovery. Repetitive stimulation studies revealed a distinctive pattern of abnormality. Activation resulted in brief potentiation of the CMAP followed by significantly greater decrement than observed at rest. This effect lasted up to 30 minutes and was not altered after intravenous edrophonium. Single-fiber electromyographic recordings during the recovery phase of the illness were abnormal with marked blocking and increased jitter. All patients were able to return home.
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Affiliation(s)
- S Connolly
- Department of Biochemistry, Newcastle General Hospital, Newcastle upon Tyne, UK
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33
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Trevett AJ, Lalloo DG, Nwokolo NC, Naraqi S, Kevau IH, Theakston RD, Warrell DA. Electrophysiological findings in patients envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni). Trans R Soc Trop Med Hyg 1995; 89:415-7. [PMID: 7570884 DOI: 10.1016/0035-9203(95)90035-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Electrophysiological studies were done on patients with systemic neurotoxicity following the bite of a Papuan taipan (Oxyuranus scutellatus canni). Evoked compound muscle action potentials decreased and increased in tandem with clinical deterioration and recovery. Nerve conduction velocities did not change in envenomed patients and were consistent with control studies. Repetitive nerve stimulation studies showed decremental responses in envenomed patients with post-tetanic potentiation followed by post-tetanic exhaustion. The findings are consistent with studies in vitro which suggested that the major action of neurotoxins in Australian taipan venom is at the synapse. The observation that electrophysiological data correlate closely with the clinical condition of the patient has potential application in the assessment of interventions in the management of snake bite victims.
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Affiliation(s)
- A J Trevett
- Department of Clinical Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
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34
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Trevett AJ, Lalloo DG, Nwokolo NC, Naraqi S, Kevau IH, Theakston RD, Warrell DA. Failure of 3,4-diaminopyridine and edrophonium to produce significant clinical benefit in neurotoxicity following the bite of Papuan taipan (Oxyuranus scutellatus canni). Trans R Soc Trop Med Hyg 1995; 89:444-6. [PMID: 7570895 DOI: 10.1016/0035-9203(95)90051-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Progressive systemic neurotoxicity is a common feature in patients envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni). Respiratory paralysis, which commonly results, accounts for considerable morbidity and mortality. Established neurotoxicity does not respond to antivenom. In this study, a combination of clinical and electrophysiological variables was used to assess the effect of edrophonium and 3,4-diaminopyridine in patients with significant neurotoxicity. Both drugs produced minor electrophysiological and clinical changes in envenomed patients. This effect was maximal when the 2 drugs were used in combination, but was insufficient to be of significant clinical benefit. Neither drug can be recommended for use in the management of Papuan taipan bite.
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Affiliation(s)
- A J Trevett
- Department of Clinical Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
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35
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Nowak MA, May RM, Phillips RE, Rowland-Jones S, Lalloo DG, McAdam S, Klenerman P, Köppe B, Sigmund K, Bangham CR. Antigenic oscillations and shifting immunodominance in HIV-1 infections. Nature 1995; 375:606-11. [PMID: 7791879 DOI: 10.1038/375606a0] [Citation(s) in RCA: 262] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A typical protein antigen contains several epitopes that can be recognized by cytotoxic T lymphocytes (CTL), but in a characteristic antiviral immune response in vivo, CTL recognize only a small number of these potential epitopes, sometimes only one, this phenomenon is known as immunodominance. Antigenic variation within CTL epitopes has been demonstrated for the human immunodeficiency virus HIV-1 (ref. 11) and other viruses and such 'antigenic escape' may be responsible for viral persistence. Here we develop a new mathematical model that deals with the interaction between CTL and multiple epitopes of a genetically variable pathogen, and show that the nonlinear competition among CTL responses against different epitopes can explain immunodominance. This model suggests that an antigenically homogeneous pathogen population tends to induce a dominant response against a single epitope, whereas a heterogeneous pathogen population can stimulate complicated fluctuating responses against multiple epitopes. Antigenic variation in the immunodominant epitope can shift responses to weaker epitopes and thereby reduce immunological control of the pathogen population. These ideas are consistent with detailed longitudinal studies of CTL responses in HIV-1 infected patients. For vaccine design, the model suggests that the major response should be directed against conserved epitopes even if they are subdominant.
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Affiliation(s)
- M A Nowak
- Department of Zoology, University of Oxford, UK
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36
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Lalloo DG, Trevett AJ, Korinhona A, Nwokolo N, Laurenson IF, Paul M, Black J, Naraqi S, Mavo B, Saweri A. Snake bites by the Papuan taipan (Oxyuranus scutellatus canni): paralysis, hemostatic and electrocardiographic abnormalities, and effects of antivenom. Am J Trop Med Hyg 1995; 52:525-31. [PMID: 7611559 DOI: 10.4269/ajtmh.1995.52.525] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
One hundred sixty-six patients with enzyme immunoassay-proven bites by taipans (Oxyuranus scutellatus canni) were studied in Port Moresby, Papua New Guinea. One hundred thirty-nine (84%) showed clinical evidence of envenoming: local signs were trivial, but most developed hemostatic disorders and neurotoxicity. The blood of 77% of the patients was incoagulable and 35% bled spontaneously, usually from the gums. Fifty-one per cent had microscopic hematuria. Neurotoxic signs (ptosis, ophthalmoplegia, bulbar paralysis, and peripheral muscular weakness) developed in 85%. Endotracheal intubation was required in 42% and mechanical ventilation in 37%. Electrocardiographic abnormalities (sinus bradycardia and septal T wave inversion) were found in 52% of a group of 69 unselected patients. Specific antivenom raised against Australian taipan venom was effective in stopping spontaneous systemic bleeding and restoring blood coagulability but, in most cases, it neither reversed nor prevented the evolution of paralysis even when given within a few hours of the bite. However, early antivenom treatment was associated statistically with decreased incidence and severity of neurotoxic signs. The low case fatality rate of 4.3% is attributable mainly to the use of mechanical ventilation, a technique rarely available in Papua New Guinea. Earlier use of increased doses of antivenoms of improved specificity might prove more effective.
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Affiliation(s)
- D G Lalloo
- Department of Clinical Sciences, Faculty of Medicine, University of Papua New Guinea, Boroko
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37
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Trevett AJ, Lalloo DG, Nwokolo NC, Naraqi S, Kevau IH, Theakston RD, Warrell DA. The efficacy of antivenom in the treatment of bites by the Papuan taipan (Oxyuranus scutellatus canni). Trans R Soc Trop Med Hyg 1995; 89:322-5. [PMID: 7660450 DOI: 10.1016/0035-9203(95)90562-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A prospective series of 156 patients systemically envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni) were studied. All patients were treated with appropriate antivenom and clinical course and outcome were compared. The proportion of patients requiring intubation was significantly smaller, and the time to resolution of neurotoxicity and discharge from hospital significantly shorter, in patients receiving antivenom no more than 4 h after the bite. No significant difference in outcome was demonstrated between patients receiving antivenom at various times after 4 h. No difference was demonstrated in the times to restoration of coagulability between the 2 groups. The only significant difference between a small number of patients given 2 vials of antivenom and patients given a single vial at the same time after envenoming was a marginally shorter duration of intubation in those who required it. The study suggests that, to achieve significant clinical benefit in Papuan taipan bite, antivenom must be given as early as possible.
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Affiliation(s)
- A J Trevett
- Department of Clinical Sciences, University of Papua New Guinea, Port Moresby
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38
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Trevett AJ, Lalloo DG, Nwokolo NC, Theakston DG, Naraqi S, Warrell DA. Venom detection kits in the management of snakebite in Central province, Papua New Guinea. Toxicon 1995; 33:703-5. [PMID: 7660375 DOI: 10.1016/0041-0101(94)00179-c] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The bites of six species of venomous elapid snakes in Central Province Papua New Guinea produce similar clinical syndromes. Optimal management of envenomed patients involves the use of monospecific antivenom. In this study, Venom Detection Kits (VDKs) (CSL Diagnostics, Melbourne) were used to try to make a specific diagnosis in envenomed patients at their admission. VDKs detected venom in admission bite site swabs from 39 to 46 patients (85%). Thirty-eight of these patients were shown to have been bitten by taipans. In all cases where venom was detected by the VDK, this correlated with subsequent laboratory enzyme immunoassay results. Selective use of VDKs in Central Province could allow more widespread use of monospecific antivenoms and produce considerable financial savings.
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Affiliation(s)
- A J Trevett
- Department of Clinical Sciences, University of Papua New Guinea, Port Moresby
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39
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Lalloo DG, Trevett AJ, Saweri A, Naraqi S, Theakston RD, Warrell DA. The epidemiology of snake bite in Central Province and National Capital District, Papua New Guinea. Trans R Soc Trop Med Hyg 1995; 89:178-82. [PMID: 7778143 DOI: 10.1016/0035-9203(95)90485-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Snake bite is an important medical problem in some areas of Papua New Guinea and appears to be most common in the Central Province and National Capital District. The overall incidence for Central Province is 215.5 per 100,000 population, but Kairuku subprovince has an incidence of 526 per 100,000, which is amongst the highest in the world. The clinical pattern of envenoming also varies within the Province, suggesting that different species of snake may be responsible for bites in different areas. Most envenomed patients are bitten during daylight on the lower limb and are rarely able to describe the snake. The mortality rate in Central Province is 7.9 per 100,000; most patients die from ventilatory failure due to severe neurotoxicity. Mortality might be reduced by increased use of compression bandaging as a first aid measure, earlier treatment with antivenom and earlier referral to hospital.
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Affiliation(s)
- D G Lalloo
- Department of Clinical Sciences, University of Papua, New Guinea, Port Moresby
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40
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Lalloo DG, Trevett AJ, Owens D, Minei J, Naraqi S, Saweri A, Hutton RA, Theakston RD, Warrell DA. Coagulopathy following bites by the Papuan taipan (Oxyuranus scutellatus canni). Blood Coagul Fibrinolysis 1995; 6:65-72. [PMID: 7540879 DOI: 10.1097/00001721-199502000-00011] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The mechanisms of haemostatic failure were studied in 87 patients bitten by the Papuan taipan (Oxyuranus scutellatus canni). Eighty (92%) had evidence of a coagulopathy on laboratory testing; 36 (41.4%) developed spontaneous systemic bleeding, although this was rarely of clinical significance. Coagulation assays in 48 completely defibrinated patients showed marked reductions in factors V and VIII and reductions in factors II, IX, XI, XII and XIIIA. There was a reduction in plasminogen and alpha 2-antiplasmin levels and both total and cross-linked fibrin(ogen) degradation products (FDP) levels were elevated. The mean platelet count was initially decreased and fell further during admission. Similar but less severe changes were seen in patients who were mildly defibrinated. Following treatment with antivenom, fibrinogen levels rose rapidly and coagulability was restored within 6-12 h in 93% of patients. These abnormalities may be primarily attributable to the prothrombin activator present in taipan venom, but it is likely that other uncharacterized venom components contributed.
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Affiliation(s)
- D G Lalloo
- Department of Clinical Sciences, Faculty of Medicine, University of Papua New Guinea
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41
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Trevett AJ, Lalloo DG, Nwokolo N, Kevau IH, Warrell DA. Analysis of referral letters to assess the management of poisonous snake bite in rural Papua New Guinea. Trans R Soc Trop Med Hyg 1994; 88:572-4. [PMID: 7992343 DOI: 10.1016/0035-9203(94)90168-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A prospective series of patients envenomed after snake bite was seen at Port Moresby General Hospital (PMGH), Papua New Guinea, between January 1991 and December 1992. Referral letters were received with 60 of the patients who had been initially seen at a health centre. These letters were analysed in conjunction with our own clinical observations. The importance of non-clotting blood and local lymphadenopathy as early signs of systemic poisoning did not appear to be universally recognized by staff in health centres. In some cases, no attempt was made to transfer the patient to hospital until signs of neurotoxicity were established with potentially dangerous delay. Analysis of both hospital and health centre records suggests that the majority of deaths which occurred in Central Province, Papua New Guinea, during the period of the study were due to delay in transfer to hospital. We suggest that all patients with unequivocal signs of envenoming in Central Province, Papua New Guinea, should be transferred to PMGH as soon as possible. Antivenom should also be given as soon as possible, but this does not remove the need for immediate transfer.
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Affiliation(s)
- A J Trevett
- Department of Clinical Sciences, University of Papua New Guinea, Boroko
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42
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43
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44
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Affiliation(s)
- A J Trevett
- Department of Clinical Sciences, University of Papua New Guinea, Port Moresby
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