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Great, lovely. Well, thank you very much and welcome, everybody. Um, I see that we've got a nice, intimate group which will work really well for this lecture. I'm talking about tropical and travel related infections, but obviously, I cannot cover everything because there are, um, so many and more emerging on a daily basis. But I find this quite an exciting and interesting topic. Um, and what I hope that you're going to get at the end of it is an approach to a patient who has come from somewhere other than where you are practicing medicine. Um, when you see them, um, which is something that we are increasingly seeing with the mobility of, um, populations of people and people, as you very well know. Um, and I feel like, uh, this is something that I don't have a right to tell you. But, you know, more than anyone else, um, how people are both having to move across the world as well as others having the luxury to be able to travel, um, for all sorts of different reasons that are not necessarily through necessity. Um, but what I want you to get by the end of This is an approach to dealing with those patients'. So, um, we need to think about the patient's that we see within the context of what is circulating where they have been now who they might have been in contact with and where they've been. But also, we need to think about what circulating in our own environment, that might be what they're presenting with because one of the big mistakes people make when patient's present them having traveled somewhere is they get so excited about the fact that they've been in exotic parts of the world are different parts of the world that they actually forget, that they've been back in the country where were practicing for a while, and they might very well not be presenting with, um, something exotic or interesting, but just a bog standard infection that they would have got, um, going to school or traveling on the bus. Um, so we always need to think about those two things in concert when we have a patient who has been traveling, always come from elsewhere. So what I'm going to do because I'm going to talk you through six different cases and, um, we've got 11 of you on now. So they're about. So that's I think about nine students. Um and I'm not sure what what stage you at, but I'm going to do an experiment and ask you to, um, switch on your microphones, Um, as as and when you want to speak so we can start a discussion. Each of these six different cases demonstrate something important. Um, which will inform the approach you take two a possible imported infection and how to make the correct diagnosis in as timely fashion as possible. So these are the big three. Um, and I'm showing you Sorry. Let me put this on the slide. Um, and I'm showing you the big three because I'm not going to talk about them and the big three of tuberculosis, HIV and malaria, which affect Children in large swathes of the world and are hugely important, but because they're so important, they each deserve a lecture of their own. Um, and I would very much like, uh, you to put in the chat. Um, and perhaps Hannah could collate and let me know, um, whether you've had lectures on these before in Children. And if you would like them Because then I shall make a plan to talk to you about those at a later stage, and, um oh, because I'm a pediatrician. Um, this is the other disease that is incredibly important. And although we do have a vaccination for it has not unfortunately, disappeared from the world, um, and will continue to cause problems. And again, I've spoken to about measles in the vaccine preventable lecture. Um, but I'm happy to do more to later stage. So let's think about all our patient's who present us. Every child who comes to see a physician, um, or a nurse or who presents to health care of any kind is a mystery until a history is taken and the patient is examined. Now your examination starts, and I've said this and other lectures before, as soon as you walk through the door and clap eyes and a child because the most important part of an examination of a child is observation. So while you are talking to the patient, um, and talking to the caregivers, you'll be looking at that child watching them, um, and making observations about how they how they are and, um, how they are behaving from the moment you walk on the door and you will notice how they lie. You will notice the, um, level of consciousness. You will notice respiratory rate. You will notice rashes. So there's a huge amount of information that you can gather in a very, very short period of time just by observing your patient's. And the reason why I keep on emphasising. This is because, particularly with young patient's, um, they're not like adults who will lie still and who will cooperate the moment you lay hands on them. You lose the opportunity to gain a lot of information because they don't like it much. And you also have to be quite opportunistic in what you do and when. So you would never examine a throat or I or ears, um, at the beginning of an examination, because that's the quickest way to lose, um, the cooperation of a young child. Sorry, that's an aside. So the first thing you would you would notice when you walk through the door is how old is this child? And then you would be making an assessment of how unwell this child is, and that seems to be a very vague, Uh, comment. But you are processing all that information as you are looking at this child, and and it becomes relatively simple to make that judgment. This child is not particularly unwell, but has a problem versus this child is very, very unwell and needs intervention very quickly. Which means that your opportunity to, uh, to make allegedly diagnosis, uh, is not necessarily there. So that that would be the first observation you make. Um, again, I've spoken about IMC either integrated management of childhood illness. And if you weren't that lecture, I'm sure you can find the recording. And that is a really good UNICEF and W H O toole, um, to help you make a judgment call on how and well or otherwise a child is. And I would strongly recommend going on those websites and downloading it. It is designed for, um, for healthcare professionals in very resource constrained settings, um, with few resources and who don't have a great deal of training. But it is incredibly useful, I think, for anybody, because it provides a structure, um, and and the basics of how to make that assessment. Then you want to know where is this child from Is this a child who comes from the country in which you're working, who has traveled outside and elsewhere? Or is this a child who has lived somewhere else and is newly in the country where you are working? Uh, because that will inform how you think about what they've presented with. And who has this child been in contact with? Has he been in contact with huge numbers of other Children? Lots of adults. What kind of environment has he been in? Is it an environment where which is a luxury environment where he's had all sorts of resources? Has it been urban? Um, what has what has he been doing and what people has he been in contact with? And we're going to talk more in detail about that. So the basic principles are you gonna take a very full infectious disease history and examination. Um, and this is a joke in medicine Is that the infectious disease physicians are the most intrusive when asking about histories and examinations, because we want to know absolutely everything about everything because we really detectives. And it's about picking up those little clues that will point us in the direction of the diagnosis. It's useful to have knowledge of countries visited and the diseases that are found there. But realistically, you cannot carry that all in your head. Um, it's not possible. You will know broadly in different regions. Um, what to expect? So you know that if somebody has been to sub Saharan Africa or to the Indian subcontinent, you might be thinking about, um, about malaria. But you can't, um, if you can't necessarily, um, no, and carry everything. But what you do need to do is be aware that where they've come from somewhere else that you might there might be something that you don't know about that is happening in that part of the world. And then you go, um, to a different resources for, um, for information, this isn't a test. Uh, use the resources you have, so you would look on the CDC website, the W H O website, And in this country, uh, it used to be the Health Protection Agency, but it's now public health England. And what you'd want to know is, um, is there anything endemic in the country they've come from that there might have been, uh, exposed to, Or Is there something an outbreak happening there and very often? If there's a quite spectacular outbreak, we would probably know about it because we would have read about in the in the media, Some seasonal knowledge. What, um, what season is it where this patient has come from? Is it some? Is it winter? Is it spring, Um, and crucially, what is happening, where you are and where that child is now. What is circulating? Because if a child has been back from their travels or has been in the country for a week or more, they could very easily have picked up something that is circulating in the environment. Don't forget what's happening at home and don't forget things that are really common, um, and occur everywhere. So when you're thinking about Children who've come from elsewhere and about a possible important infection, you must also make sure that the other stream that you're thinking about is what's going on here and what is really common wherever in the world you are. So if you have a baby with a fever and you can't find a source of infection, you have to think about a urinary tract infection. You have to think about respiratory infections. You have to think about, um, about sepsis and other bacteria infections because that can happen wherever you are. And you can pick that up anywhere in the world. So what questions do we ask when we're taking an infectious disease history? We want to know. Where's this child been? Um, and how long this child has been there for? So, um, has the child been INR oral areas? Has the child been in urban areas? Um, what kind of environments are they have there been on a farm and in contact with animals and eating unpasteurized food? Sipes, um, and milks is an urban environment. Is it an urban environment where there might be exposed, um, to open sewerage or two, Um, or too poor running water, Um, and to food stuffs that have not been properly washed. Um, all of those things are important when you think about what is going on for that child. What foodstuffs have they eaten and an immunization history. Now we have a tendency to write in the history, um, immunizations, complete or up to date. But it is more and more important as Children are moving around. Um, and people are more mobile, too, right? Exactly what immunizations patient's have had. And the reason for that is that the immunization schedules in different parts of the world are slightly different. Um, immunization is disrupted by war is disrupted by outbreaks. Um, movement of people. Um and so we need to know precisely what they have and haven't had. Different parts of the world might have vaccinations that are not routine elsewhere, and the timings that they given can also be different. So particularly with younger Children, you need to make sure that you ask those questions. Who have they been in contact with? Children who have traveled across continents, who've been in contact with lots of people from lots of different places. Um, perhaps in very unsanitary, um, and crowd ID areas could have had endless contacts. You're not going to be able to tease out exactly what we're and how. But knowing that is important information. Um, if they've been to a particular place on holiday, um, or have have been there for a reasonable length of time or have lived there, um, they will be able to give you some idea of who they've been in contact with. Um, and this is this is quite crucial. Listen to what they say. I remember very clearly when I was working in Philadelphia and a really prestigious hospital. Um, we had a child who came in through the any department who presented with malaria. And the reason we diagnosed malaria was because this childhood had a seizure. Uh, and because she had a seizure, she had brought herself a full blood count in the a N D department. The ER and I got a hysterical call from the lab technician saying, Oh, my God, we're seeing parasites on the film. And I went downstairs and there were those parasites on on a normal smear looking, um, looking at the at the white blood cells, Um, and she had a parasite count to 40%. And the story behind this was this child. I had come from Sierra Leone. She was an American child who had gone with her family to, um, to visit, uh, extended family and war had broken out and because, um, the Americans were airlifting all their citizens out of Sierra Leone. She was part of that airlift and was and landed on the East Coast and she worked away up the east coast of America with the story, um, in any departments all the way. Uh, to us, we were about the third or fourth, Um, any department and nobody had picked up the clue that she'd come from a country where malaria was endemic. Um, she was in a war situation, had been airlifted out, and therefore taking prophylaxis was probably not on anybody's mind. And that this was, um, was a possibility. So be aware, um, of circumstance, Um and, um, and listen very carefully to the patient's, um because if somebody had listened to her earlier on, the diagnosis would have been made earlier. Um, and that's another important lesson is that if you're in a country where diseases are endemic, um, you probably are are more likely to have a diagnosis made more quickly, and that's something that we need to be aware of. And we need to listen to the parents and to the caregivers. Um, when they tell us things, um, like that and they will have knowledge of what's going on locally where they've come from often not always, but they might what animals have they been in contact with, um, Are these wild animals or these domestic animals? What is the environment? And some people do very interesting activities and are out, for example, in caves or climbing Mt. Um, and are exposed to all sorts of different pathogens in those particular places out in forests. They might be exposed to text or two, um, or two different, um, mosquitoes. And what time of day they're out is also important. Um, what are they doing? Um, if you've got a baby, they're very unlikely to be doing much. Um, but if they parked outside in a pram by their parents, um, to sleep in the sunshine, um, or in the fresh air, they might be exposed to, um to biting insects. Um, but they will not be exposed to the types of things that you might get from, Um, uh, spelunking caves or climb the mountains. What season is it? Is it spring? Is it winter? Is it summer? Different organisms will circulate more widely at different times of year and then issues that are local to wherever you are traveling. So here are the core questions, and these are these are the things, um, the questions you must always ask, and it provides you with a structure to your history. Who is the patient in front of you? Where have they been? What have they been doing? Why have they been doing it and when have they been doing it? So I'm going to start you through cases. So what I'm going to ask of you Because they're now 13 of you online, Um, is, please a new a new it yourself if you have a question, um, or you want to add something and let's try and make this, um, interactive. So our first case is a five year old boy who was previously completely, well, developmentally normal. Um, he's fully immunized, and he comes to you with a four day history of abdominal pain. He's got, um, dysuria. So he's got pain on urination, and he's got a little blood, um, in his urine, and he's got a bit of a rash over his legs. So we then look at him and I'm deliberately not giving you information, because I want you to ask for it. And he's well, he's a fibril. Um he looks absolutely fine, but he's got this funny Fine, fine. Rash over his legs, Um, bottom of his legs. Doesn't have any tenderness. Doesn't have any spleen, um, or liver. And when we dipsticked his here and he had some red cells. Okay, So what are we going to ask? Can I have somebody to start this off? What do you want to know? Um, So we we read a couple of, uh, a bit of information there regarding, um, his urine. But then you changed the slide. Was it? He just He just had some He had some red cells in his urine. Yeah. Um, so maybe we can ask, um, if If everything is okay with urination, for example. Um, do they urinate often? Is it has anything changed? Uh, any changes there? Um, he's urination has always been fine, But what he finds is when he urinates right at the end, just as he's finishing urinating, he has this very sharp, sharp pain. Um, which is is quite excruciating. Mhm. Okay, um, then I will ask if they are up to date with their immunizations. Yeah, I mean, he is, um, any allergies or allergies? Uh, and I'll ask if they've had before any UTI infections or any? No, it never had UCS before Any back pain or back pain. I don't know if any of my colleagues wants to help me. Okay, this is I will. So, yeah, go ahead. I will start from the beginning, Uh, from birth History? Yes. Normal child. Well developed, Uh, any other, Uh, you know, medical history. The child has any family history genetically, Anything that I've been, uh, level and driving and all those completely. Well, okay, then, uh, an examination to see what's happening. Fine. It's got this funny little rash over his legs. Really? You know, just little little red dots all over his legs. Um, but it's fine. No other rash anywhere in the body or a jewel rush? No. Nope. He's jumping around, jumping around, Happy as anything. Um, but his parents just say that as soon as he finishes weighing, he cries with pain. Um, and they've noticed this funny rash, Any cough, coryza little symptoms, anything? Absolutely well, otherwise Okay. Okay. Vanilla. You wanted to say something? Yes. Has he ever had anything in his head like any kind of lights or no. Has he ever had any problem when he goes to the toilet. Any worms or pine? No, no. Uh, and his parents, They don't have any condition that hasn't eaten anything funny. No bites. Immunizations are all completely normal now. What else do you want to know? The clues on the slide food recently. What? He's eaten? No, nothing unusual. Same stuff he always eats. Pizza, fish and chips. Uh, animals at home. Flea bites? Uh, animals. No flea bites. So when did everything start? Ah, Now, that's an important question. Um, everything sort of started about a week ago. And what makes it worst? Nothing makes it worse just every time he wheeze. So just that's it. There's not a pattern on just days at night. Uh, no. Just when he would ease. So just based on Okay. Okay. Um, would you like, Would you like me? Let's Let's see what people have said in the chat. Um, I can't open it for so far. There we go. Um, uh, right, um, activities And where? All right. So that's That's an important one. Where's he been? Um, that's a question we need to ask. Uh, and this child has been with his family in Southern Africa. Um, they've just returned. They lived there for about a year. His parents were missionaries. Um, and the family were living in Malawi. Um, so and they've been back for about a month. Six weeks? Um, and this has just started. So they know all about what's going on in, um, in Malawi because they've been there for a long time. But if you don't ask the question, you're not going to get the answer. And if you don't ask the right questions, you're not going to get the right conclusion. So they've been in Malawi. Um, they've been there for the last year. Um, they've been there because they're missionaries. Um, and they've been living there. So what's he been doing while he's there? Obviously he's going to school. Um, he's a young boy. It's hot. He'll be out, um, and about. And swimming, which is one of the major activities. And where's he been swimming. He's been swimming. Um, sorry. Excuse me one sec. I'll be back back. So, Dean, can you come upstairs, please? Do the fried. Uh huh. Apologies. Um, one set. Apologies, guys. So he has been swimming, and he's been swimming in Lake, Malawi. Now, the parents are absolutely adamant that he didn't go swimming in Lake Malawi because they know that he can become infested with a parasite there. Um and, uh, I'm going to ask you now, what parasite is this? Anybody know exactly? Just a some isis. But they know all about it because they've lived there for the last year. Um, and so they didn't let him go swimming in Lake Malawi. They're adamant about that. Now, you show me a child who's not been swimming in water when they have an opportunity, and I'll show you a child who's not walking. Um, but they've lived there for a while, so obviously they have not, um, not had, uh he's potentially been with other people where he might have picked it up. Um, he might have gone swimming. So, you know, that's something to think about. And that is exactly what we're dealing with. So, what investigation would you want to do? If you've got one investigation you can do? What would you do? Anyone? Okay, I'm going to move along a bit because you've got a few cases to get, perhaps a stool exam. Um, you're on the right track, not a stool exam, and I'll show you why you're absolutely urine. Yeah, And what you want to do is you want to look in the urine under low, um, power microscopy. And this is what you'll see And what this is as a hematoma, um, egg, which gives you the diagnosis straight away. Um, And the eggs have this little, um uh, spike on the end of it, which is what is causing the pain. Because when he pees, that spike is catching on his urethra. Um, and that's what's causing the pain. Now you can tell what kind of justice? Um, isis, it is based on where the spike is on your egg. Um, and this is hematopoietic because the spike is on the end. Um, Ansonia, which is what you'll find in the stool, has a spike on the side. Um, and then there are other species as well. Um, which I'm going to talk to you about now. But hematopoietic is the main, um is the main species that we see in that part of African sub Saharan Africa. So, um, you get s Hemet Obeah manzoni a japonica Mekongi, um, with hemato be in, uh, men's only being the most important. Um, and you see it in lots of parts of the world, but we tend to associate it most commonly with sub Saharan Africa, with Malawi being really ground zero. For that, the incubation period is long. It's 10 to 12 weeks. So he's been back for four weeks. He's been well, and he probably picked it up a while before that. Um, and that is important because when you want the diagnosis, um, and you're thinking about serology, it will take up to 10, 12 weeks before your serology is going to be positive So you can distill microscopy if you think it's man Sonia. But, um, urine, um, is is the investigation of choice for him a Toby? Um, and treatment is very simple. It's pricey quantum for three days, and that's a that will kill the worm that is producing the egg. Um, you might have positive serology for a while, and you might have eggs for a while. So this is where you find different types of just a psoriasis. You can see urinary. Um uh, just a psoriasis up in Egypt where it's very common. You'll see both types throughout the whole of Africa. And then you have hepatic and intestinal, uh, in China, with the rest of the world being relatively low risk. Okay, let's move on to the second case. Now. This is a seven year old boy who's previously fit and well, but over the past four days he's had a rash. He's had fever. He's had really severe headache. He's had nausea, vomiting and anorexia, and bad abdominal pain and diarrhea. Okay, And on examination, he's really, really unwell. He's got a temperature of close to 40. He's got a very high pulse rate of 100 and 70. His BP is lowish. He has a capillary, a prolonged capillary refill time. He's got this very bad headache. He's photophobic, so he's clearly has a meningitis component with mark neck stiffness. He's got a gallop on cardiovascular exam. Um, I would suggest that there's a systemic septic element. Um, his abdomen is soft and you can feel the edge of the liver. And he has this rash all over his, um, his body, but particularly he has it over the palms and over the soles, um, of his feet as well as, um his legs and his trunk. Okay, So what are we thinking here? All right. Uh, we can ask if anyone else at his school has these symptoms. No. Nope. Everybody else as well? Yeah. Again. For how long? When did it start? Okay, it's been the last few days. Um, he's very acutely unwell, So his parents have brought him quite quickly after these symptoms and signs started. Um, and you said low appetite, didn't you? You said low appetite of in. Yeah. Yeah. Yeah. So it may be, uh, is he vaccinated for measles and he's vaccinated for everything. Including, um, meningococcal disease. Um, has he had any epileptic fits or any seizures? Nope. He hasn't had any seizures. No. Again, Um, I think, yeah, after asking all these questions. So how is it progressing and everything? Then we will examine him, won't we? Yeah, I've I've given you the examination, but I think, um, there there are a few things to ask you now. Firstly, how quickly do you have to move with this child? This is this is very different to the first child where you can take your time because he's systemic. He was systemically. Well, this child is a different proposition, isn't he? He's clinically unwell. So he's septic. He's septic. He's clinically unwell. We have to move really fast. Um, so we want to start with supportive therapy. We want to make sure that he has fluids. Um, he's septic, so we would want to give him some antibiotics. Um, but we also need some more information. So there there are lots of questions that you have not asked me that are important. Travel history, anything. Yeah, absolutely. So travel history is important, and the other thing is time of year. So this is a child, Um, And I'm saying he's in the UK now because that that's what, um, what will help, uh, this discussion. And it is, um, September. And so it's the beginning of the school year, and it's the end of the summer holidays, and that's really important. And and those the kinds of things you need to consider when you see these patient's, because that's the time when people travel. If they're going to travel, they will travel during the school with Children. They'll travel during the school holidays, so it's going to be the Christmas holidays the Easter holidays and the big travel will be over the summer. So, what you want to say? The question you want to ask is Have you been anywhere? If Yes, where have you been? And what have you been doing? And where this child has been is he's been in the United States of America. Um, and he was there for four weeks. Um, and he went, um, to visit family, and they were staying. Um, and I think it was North Carolina. Um, So what else do you want to know? Have there been outdoors? Absolutely. Of course, they've been outdoors because it's the summer and the kids have been outside all day, every day, um, running around. He's been running around with his cousins on bikes in lakes. Um, you know, hiking. Uh, they went mountain climbing. They've had a really active holiday. I've been thinking about lying. This is That's a really good thought. Um uh, but would lime cause this kind of acute illness? Uh, maybe many diabetes. Good thought. What kind of meningitis did any of the other Children been unwell? Because he's been with lots of other group of Children, know everybody else has been fine. Okay? There's something on here that we've not talked about. And he was no bites. He said he hasn't? No, he Well, he's been out and about him. Yes, he did have lots of bites. There are lots of insects. And Dix and, um, you know, all sorts. And he's been outside in nature. And the parents went, Oh, you know, they all had lots of bites. We didn't take much notice. Just remove the ticks. And, you know, it's common there. Everybody gets it. It's okay, that is really good. And you are absolutely on the right track. So let's look at the investigations now. His full blood count doesn't look very nice. He's got him. Globin is low, white count is low, neutrophils are high ish, and the lymphocytes platelets are very low. And he's got a very, very low sodium. Um, potassium. You're You're really creating everything, um, is deranged and abnormal. This is a very sick child, and he's got clotting abnormalities. Okay, so this is the point at which you say to the parents, Are there any diseases in that area that you know of? And you would if you don't know you would call your local I d person, you would go to the CDC, w h o website. Um, or you would ask your senior or if you are the senior person. Um, you would find out what's going on in that region because this is a very unusual combination of abnormalities. And this is the point that you are admitting this child probably to an intensive care unit or high care unit if you've got one. Okay, so let's talk about what this is. Whoever said tick bite fever is on the right track. This is Rocky Mountain spotted fever. Um, would you get throughout the states, But, um, as, uh, you find it in the areas of the Rocky Mountains. Most commonly, um, and it's caused by rickettsial disease. It's an obligate pathogen. Um, and it's tick borne. So you get it from, um, eggs, Adi's species. You find it in the spring and summer. So that's when he's been out and about. You tend to find it in younger Children under 15 years of age, and you find it throughout the state. The incubation period is quite short. It's 2 to 14 days, and he returned from States. That's why I said the beginning of the of the winter term. He'd just come back from the summer holiday a week before, So he had picked it up in the last days of his holiday. You diagnosed it by IMMUNOFLUORESCENCE essay about 7 to 10 days after the onset of illness. And the reason why I've talked to you about this and and the point that I'm making with this case is that if you don't think about it, you're not going to be able to diagnose it. And you're not going to be able to treat it because this is a very sick child. And what you need to pick up is the inconsistencies between this disease and a meningitis he is presenting with the meningitis, and this could very easily be mistaken for meningococcal disease. But it's the wrong time of year. And, um, your there are inconsistencies in the blood results that you've got there. Um, and in the presentation, um, and knowing where he's been, uh, you need to think about this disease because it's not treated the same way as we would treat a meningococcal disease. And a broad spectrum antibiotic is not going to cut it, you would need to give doxycycline or chloramphenicol or flura quinolones so not what we would probably use, um, for a meningitis. And if you don't give him those, then you're going to lose this patient. Okay, so any other questions before we move on? Okay, let's look, let's look at the next case. This is a nine year old boy who's presented with fever, headache, neuralgia, arthralgia, nausea, vomiting, rash. Um, so you know, similarities to the to the last case. But what is different? Does he have has muscle pain and he has joint pain? Um, and he's has headache, which the previous one had, but he's got nausea and vomiting, which the last patient didn't have, and he's got a rash. But this is a different rash. So when you examine him, he's got some meninges. Um, he's got a very erythema, tizen diffuse rash. Um, and his gums are bleeding. He's also photophobic, and he's got plural effusions. He's got, um, fluid in his abdomen. He's got ascites, and he's in acute shock with low platelets, so there are quite a few similarities to the previous patient. Um, but there are things also that are different because he's got a lot of fluid in a lot of different places now. What would you like to know Would collect a general history about the child? Okay, history, immunization, history, history and all those things. Okay. This is a child who's relatively well. He's had a few flu like illnesses over the years. He's back and forth to visit his extended family in Where are they? They're in. I think that they're in Thailand, Some in the Caribbean, Um, and some in Africa. Very widespread, but he's visited a lot of different places. Um, Caribbean mostly. Um, no Unusual food stuffs, uh, and yeah, you know, wherever he is, he gets bites. But that's kind of standard. You know, when you travel, too, too hot places. Um, and that's, uh that's a problem. You know that the family regard as as one of the downsides, um, get bitten by mosquitos, and they do their best to try and minimize that. Um, he was in the Caribbean with his, uh, family over the summer. Um, and, you know, in the past, he's had some flu like illnesses, but nothing more than that. Okay. Investigations a full blood count. I mean, where it start from, you know? Yeah. OK, sorry. I'm going to show you. I'm gonna This is a sit tried. So you're going to want to do your liver function, test your full blood, count your crps. You want to look for sepsis? Um uh, and this is You can't see this very well, but this is, um, a very diffused, very sort of pink rash. And when you put a hand hand on it and you take it away, it leaves a handprint. So that's your your clue. Is that a planting rush? Sorry. Would you got Sorry. Any luck? Or is it the one that we do for many Guidice Doctor with a glass? Yeah. No, no, no, you wouldn't. No. No, it's not. It's not a paretic rash. The rash disappears when you put a hand on it and you take it away and you see what looks like a hand print. You know those t shirts? Where which are body heat, where you can put your hand on them and you take it away. And it looks like you've got, um, a handprint left behind. That's what it looks like Okay, right. Let's let's move on a little bit, uh, more quickly. Now, through this case, this is a case of dengue fever, um, and dengue fever. You will find in lots of different about to ask Professor if if he's bruising easily. But I didn't. Yeah, well, it's a good thought. It's a It's a really good thoughts, so you can see that throughout again. The Indian subcontinent and Asia, parts of Africa, parts of Australia wherever you have a Edie's Egypt uh, mosquitoes. Um, in fact, that's where you have a chance of finding it. So it's an album virus. It's Flavia virus. You get person. Um, no, you don't get person to person spread. I'm very sorry. That is the mistake. Deliberate mistake using this one because it's all different stages, so it's hard to diagnose it, and it all depends on what it is. Very difficult to diagnose. But I've deliberately chosen this stage, and I'm going to talk about it's not person to person. Spread, Um, and I will change the slide. It is, um, insect born. It's got a short incubating period. So the other question you need to ask is, Where's this child been. And when did he return? And he returned two days before he presented, um uh, you, uh you want to diagnose it by viral isolations, which is very difficult and more likely through serology and raised I g m. And your treatment is supportive. Um, therapy. Now, the important thing about dengue, um, which is the point that I was trying to make is that it's a disease, which gives you an augmented immunological response with the second, um, and other, um, other infections. Um, uh, after your first infection. So, uh, he's had a flu like illness in the past, which was probably his first dengue fever. Um, he then developed antibodies. And with the second, um, infection, he will present much more acutely because his body, his immune system, is responding to that. And what we are seeing with his response is an immune response. Um, and an augmented disease process. Okay, um, I've got 10 minutes less to do the next two cases, which are slightly easier, I hope, than the dengue fever. So let's let's talk them through. So we have a five year old girl with a four week history of weight loss, anorexia, fevers and lethargy. So this is quite a different case now. She's not acutely unwell, but she's had this sort of ongoing, um, sort of, uh, problematic history of a number of different symptoms that now have her family worried. So they brought her to see you because she's had four weeks of these things. So what do we need to think about? Any other associated symptoms, like cough expectations? No cough. Why do you ask that question? Well, weight loss, anorexia, lethargy. You know, pulmonary TV. Excellent. That's a really, really good thought. That's absolutely right. You do need to think about that. Um, and and this is the point with, um, with your thought processes and how you think about things. Uh, four week longer history. You thinking of a different selection of, um, potential diseases that could be causing these symptoms? What else do we need to think about? TB is an important one, but there are others that are really, really important. Um, when we see this selection of, um uh, absolutely right that is dead, right? You do need to think about your cancer's. Um, this is a five year old. This is a child who is, um, unfortunately, a perfect age to present with the lymphoma leukemia, and so that absolutely has to be on your differential. And that is really, really good thinking. Because you need to think outside of the infection box and make sure that you don't miss a cause of a fever, A cause of an illness that is non infectious in nature. Okay, that's really good, right? So when we examine her, we have lymphadenopathy. We have her patter. Splenomegaly. We have anemia. We have a low hemoglobin. We have a low white count, low neutrophils and a low platelet count. So her bone marrow has been affected. Her albumin is very low. So that's suggesting that it's been going on for a while. And on the film, you see a few blast cells. So what do you think is going on here? Immunal suppression. Um, has she been anywhere troubled history? Anything with a very good question. Yes. Her grandparents live in Spain, Um, and she goes to visit them regularly in the summer. They live on the beach in Spain and obviously there on the beach and in in the ocean all day hasn't been for two years. Um, but before that, she was there for the first, you know, with covid etcetera. She's not been. But for the first three years of her life, she was back and forth quite regularly, and they went this summer as well. But briefly, has she had any kind of fun? Jian her skin or going now, but discipline of my galley. So and have ejector urine. Uh, clear. And she's had some liver function tests. Yeah. Uh, yes. I think she's had some liver function tests. Sorry. That's what she looks like. A very big spleen. Very big liver. Um, I don't have any, uh, liver function tests for you, but they they're not nothing to write home about. Really. Not particularly exciting. I'm not sure it's that leishmaniasis, which is excellent. Well done. That's exactly what it is. Um, and and that is very, very important because, um, you thought about all the right things you thought about cancer. Um, and you thought about leishmaniasis. Now, um, which are the differential diagnoses? And very often these patient's come in and they will then be sent to us and our tertiary center with the diagnosis of lymphoma. But we need to check that they don't have leishmaniasis. Um, and the things that people don't do, which none of you have done. Um, you've been really good. Is, um is think about the length, um, over which this the this can incubate. Um, and I love making this diagnosis particularly when patient's come. Um, having had a diagnosis of, uh, a lymphoma because it's really nice to give good news and say, This is visceral leishmaniasis. You're not going to have six months of chemotherapy. What you're going to have is a couple of weeks of Amazon, and you're going to be all fine. Um, so leishmaniasis is an intracellular parasite. It's carried by sand flies, and you find it throughout the Middle East and Africa, parts of America and Southern Europe. And this is another important point is that people very often don't think of travel to places like Spain, which is so familiar as being travel abroad. Um, they don't think that it's possible to pick up a really, um, significant infection in some place that they regard as sterile a bit like the United States. Um, but remember that there are diseases in all those places. The incubation period can be years. We've had patients who presented eight years after the infections. You have to go quite far back in the history to find travel. So if you suspected keep going back in history in the history to see if they've been anywhere where they might have picked it up, you diagnosed through tissue culture, Um, and through serology. So we very often find it in the bone marrow. Um, splenic aspirate are not very common because people are scared to do them, but you'd find it in the spleen. Um, and it will be confirmed on serology, and treatment is pretty straightforward. It's using Amazon, um, which is relatively benign. You give two weeks a break, and then you give another dose. At about three weeks, there's they're slightly different regimens that you can use. Now, I've got one minute to sum up. Um, and so I'm not going to talk through the last case. Um, that's our distribution of leishmaniasis and all sorts of different parts of the world. Um, but, uh, you will be able to look at, um, this last case. Sorry. This is case five. I'm going to run through it quickly because it's an important one. It's a six year old with a history of fever and a sore throat who is lethargic with difficulty in swallowing in a swollen neck and tingling in the legs. Um, high fever, lethargic, shocked Mark, cervical lymphadenopathy and a film over the fangs and tonsils. And she's got a very labor BP. And I'm going to tell you what this is because this is something that we, unfortunately are starting to see again. And this is diphtheria, and you can see that she's got a swollen, very swollen neck. Um, and she's got, um, some gray film, and this causes autonomic instability, which is why her BP is all over the place. Um, and it's really important because it is something that we do see in refugee situations. And we've had a tragic case here where somebody does died recently of the theory. So it is starting to, um, to rear its head, and there have been outbreaks in Eastern Europe. Humans are the only reservoirs, It's respiratory spread. Um, and you need to treat with penicillin, you can use an antitoxin. Um, so we've had a good discussion about four of those cases. I'm sorry we didn't have time to discuss the last few a bit more. Um, but the important thing is a good history. Make sure you get as much information as you can and careful examination. So you need to pick up the inconsistencies, the things that don't quite fit with what is more common. That will point you in the direction that it is something unusual. Something that has been brought from elsewhere. Um, at the same time, Don't forget what's, uh, what's circulating locally at that particular time of year. Remember, common infections occur commonly. So while you're looking for your zebra, don't forget the horses that are thundering all around you. Um, and think about the circumstances with some of the patient and the family where they've been, what they've been experiencing, what's happening with them. Um, which might give you a pointed to what's going on. And then you need to tailor your investigations and your treatment unwell. Their child is. And what the history is telling you about what is going on the history and the examination. So thank you all. Thank you for your wonderful interaction. Um, I wish you all luck going forward, please. Can you fill in the feedback forms? And also, can you let, um, me know whether you want TB lectures? Um, in Children, HIV and Children lectures? Um, and then I can plan, um, with Dr Raymond to get that on your schedule. Thanks very much. Thank you very much, Doctor. Um, in response to what you just said, someone said yes, please. To those. Right. Ok, OK, we do have a lecture now. Um, the next one is coming up. Now. There's two people that have said yes to those suggestions. Lovely. Okay, I will. I will have a chat and plan them. Okay. Thank you very much. Sure. Cheers. Bye bye thing.