IMAGE DIAGNOSES

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IMAGE DIAGNOSES

Image 1听听听听听听听 Pellagra.听 A Casal's necklace around he neck is noteworthy.

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Image 2.听听听听听听听 Scurvy and a scorbutic rosary.

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Image 3听听听听听听听听 Buruli ulcer. Mycobacterium ulcerans grew after 2 months in culture. Details in Amer J Trop Med听 Hyg 61: 689-693; 1999

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Image 4.听听听听听听听 This is phytophotodermatitis caused by the photosensitizing听听 psoralen-containing compounds in the听听听 lime peel. She had had lime wedges stuck on her beer glass; the lime skin psoralens dripped down the side of the glass with water condensation and dripped on her leg. Voila, local sunburn.

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Image 5.听听听听听听听 This was Lyme disease (erythema chronicum migrans), proven serologically. Just before he travelled听 to Africa he had visited his sister in Philadelphia. She had a house on the fringe of a central park听 where there were deer. He remembered no tick bite. he responded to appropriate antibiotics.

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Image 6.听听听听听听 This was tuberculoid leprosy (TT), biopsy proven. On histology no AFB were seen and the epidermis听听 was involved with the granulomatous reaction. The lesions cleared with anti-leprosy medication over the next 6 months.

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Image 7听听听听听 He has chronic tophaceous gout, a very common clinical entity in this population. The population has a genetically linked level of serum uric acid that is a good mg% higher than the rest of the world听 and also a high prevalence of Hemoglobin E, beta-thalissemia, G6PD and combinations thereof. These are all associated with chronic or acute hemolysis and the associated increased purine metabolism.

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Image 8.听 He has Calabar swellings due to Loa loa. Microfilaria of Loa loa were found on nucleopore filtration of his blood. Filaria serology (Dirofilaria immitis antigen) was positive. He never described an eye worm

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Image 9听 These are microgametes of Plasmodium ovale. They are at times seen in periferal smears when the pH, and other features of the collected EDTA antcoagulated blood stimulate or allow such exflagellation. They should not be confused with Borrelia recurrentis

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Image 10: African sleeping sickness caused by Trypanosoma brucei gambiense.听 CSF IgG and IgM levels were sky high as was the CSF lymphocyte count. Trypanosoma were found in blood and CSF and the T. brucei PCR was positive in both.(at the NationalReference Centre for Parasitology [NRCP],听 Montreal). Trypanosoma brucei serology by the CATT test was positive at the NRCP. 听 These "objects" are Morula cells of Mott, supposidly plasma cells crammed with IgM.

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Image 11: This is Metorchis conjunctus an Opisthorchid, as is Opistorchis and Clonorchis. Infection is acquired by eating an uncooked fish, the common sucker Catostomus commersoni,听 and has been found to infect aboriginal communities from Saskatchewan to Quebec. (ref. Lancet 1996)

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Image 12:听 This is Queensland tick typhus, the forehead lesion an eschar. He had visited a vacation spot just north of Sydney, Australia in April 2000, and found a tick on his forehead the next day. He responded over 2 days to doxycycline. His typhus, spotted fever group, serology titer rose from 1:128 to 1:4096.

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Image 13: This was Leishmania (V.) braziliensis. The needle aspirate of an ulcer edge revealed amastigotes, a biopsy grew Leishmania, serology with Leishmania braziliensis and donovani antigen was positive听 (CDC Atlanta), and the PCR for L. brazilensis was positive (National Reference for Parasitology, Canada). He responded to 3 weeks of Pentostam (Na stibogluconate) by PIC line.

This sporotrichoid presentation (nodular lymphangitis) has been noted before in Central American cutaneous leishmaniasis (species?).

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Image 14:听 This was anthrax (Bacillus anthracus) confirmed by culture. The peri-eschar vesciculation was a helpful clue. He had recently helped with the slaughter of goats, pigs. He responded to doxycycline.

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Image 15听 This is the Katayama syndrome. Three months before we saw him he remembered wading in a river and developing an itchy finely papular rash on his water-exposed legs, persisting for 48 hours after leaving the water. His cough and fever began 3-4 weeks later.听听 Schistosoma hematobium eggs were found in the stool and his anti-Schistosoma mansoni serotiter was positive. Other cases have been described from this region.(CID 1995;20:280-5) He responded to treatment with praziquantel.

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Image 16: This is intraventricular cysticercosis with hydrocephalus. She had cysts in the lateral, 3rd and 4th ventricles and basalar meningitis. Her serum and CSF cysticercal Western Blot was positive as was echinococcal serology (CDC Atlanta) Multiple shunt procedures over two years always resulted within months in shunt obstruction. Prolonged albendazole and praziquantel treatements were eventually unsuccessful as were several neurosurgical evacuations of all cysts found in the lateral and 3rd ventricles. The cysts were compatible histologically with T. solium cysticeri.

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Image 17: An astute microbiology technologist noted the serpiginous tracts and brought it to the parasitology lab. Several drops of saline were pipetted onto the tract, aspirated and placed on a slide. Under the 22x22mm coverslip 22 filariform and rhabditiform Strongyloides larvae were counted. No eosinophilia had been noted in multiple examinations over the previous 3 years. This case can be called 'disseminated Strongyloidiasis' or hyperinfection. An agar plate approach to diagnosing stool Strongyloides larvae has been shown to be relatively sensitive, but is not as sensitive as a good Strongyloides serology.

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Image 18: The worm was removed and was identified as Ganthostoma spinigerum (for details see Can J Opthalmol 2000;35:35-9). A serum sample was positive, by Western Blot, for Gnathostoma antibodies, at the Dept. Micro. Immunol., University of Mahidol, Thailand.

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Image 19: African sleeping sickness encephalitis caused by听Trypanosoma brucei gambiense.听 Serum IgG and IgM levels were sky high as was the CSF lymphocyte count. Trypanosoma were found in blood and CSF and the听T. brucei听PCR was positive in both.{National Reference Centre Parasitology (NRCP), Montreal).听 Trypanosoma brucei serology by the CATT test was positive at the NRCP. Morula cells of Mott were seen in the CSF (see image 10) He also had Winterbottom's sign.

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Image 20. The classically whorled appearance of the dermatophyte Trychophyton concentricum (tinea imbricata) found commonly in SE Asia, the South Pacific, parts of Brazil etc. There may be a genetic predisposition.

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Image 21:听 He had multiple splenic infarcts with no heart murmur and no other pathology. His symptoms resolved over the next 10 days with the admonition not to do further house renovations for a week. At the time of his admission he had a normal thrombin time, fibrinogen, PTT and PT. At the time of this CT image his PTT was 59.1 (normal < 43.6) and anticardiolipin/MPL 66 (normal <16). Relatively rare anecdotal reports, in the literature from India, have described splenic infarcts in falciparum malaria. The etiology is unclear.

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Image 22: This is an eschar of tick typhus. The incubation period can be 1-2 weeks and the development of the eschar can be well advanced before the onset of systemic symptoms. When seen initially, doxycycline was given for a possible rickettsial infection in the pre-febrile (pre-systemic) phase. Fatigue and axillary tenderness resolved over 2-3 days. Acute and convalescent serology for Rickettsia conorii and Rickettsia rickettsii were <32 and 128.

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Image 23.听 Malaria associated peripheral gangrene has been reported rarely in the literature in the past 25 years, although it is frequently mentioned in textbooks as a complication of severe P. falciparum infections. The mechanism is unclear but supposedly due to microvascular obstruction from sticky schizonts and RBC rheologic changes. A contribution from shock, as in our patient, would seem likely. Our patient initially received small iv doses (renal sparing, 2 碌g/hr) of dopamine which has also been rarely associated with peripheral gangrene. The dopamine was stopped on day 2 of her admission when the toe changes were noted. The discoloration did not progress beyond day 4.

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