Presentation

INTRODUCTION

Scabies is caused by the mite, Sarcoptes scabiei var. hominis, which burrows into the

upper layer of the skin - the stratum corneum. The female lays eggs in the tracks of the

burrows. The eggs and mite proteins produce an allergic reaction and this reaction, is

responsible for the characteristic itching and rash.

Scabies is normally acquired from skin-to-skin contact with another individual who has

scabies. It is frequently acquired among children and can also be sexually transmitted.

 It

is sometimes transmitted from care providers or beddings.

The incubation period for those without previous exposure to scabies is 2 to 6 weeks.

Individuals who have been previously infested with scabies develop symptoms within 1

to 5 days of re-exposure.

CLINICAL MANIFESTATION

Classical

Symptoms

• The main symptom is itch, which usually develops within 2 to 6 weeks after

infestation.

• The itch is generalized, very intense and intractable.

• The itch is worst at night.

• History of itch among family members within the same period

Physical Examination

• Presence of small erythematous papulovesicular lesions predominantly over

anterior axillary folds, nipple area, periumbilical skin, elbows, volar surface of the

wrists, interdigital web spaces, belt line, thighs, buttocks, penis, scrotum, ankles

and typically except for the head, face, and neck in adults.

• Infants and young children may develop similar lesions diffusely, but unlike

adults, lesions are common on the face, scalp, neck, palms and soles.

Scabies burrows are most easily found on the hands, especially finger webs and
on the wrists; other sites of predilection are the feet, axillae, umbilicus, male

genitalia and breast areolas in women.

• In infants, burrows are common on the palms and soles, and sides of the feet.

They can also be found on the heads of infants particularly post auricular folds.

• The typical burrow is a serpiginous tract that measures 1cm in length. It may be

obscured by excoriation marks or by vesiculation in infants.

• The reddish-brown nodules of scabies are seen in axillary and inguinal regions,

wrists and male genitalia and these may persist for several months. These

nodules are caused by delayed hypersensitivity reaction to the female mite, its

eggs and faeces (scybala) deposited in the epidermis, rather than by an active

infection.

• Some of the lesions may be altered by excoriations, eczematisation and

secondary bacterial infection

DIAGNOSIS

• It is important to establish a firm diagnosis of scabies before treatment.

Antiscabetic therapy may aggravate other dermatoses such as atopic dermatitis

and cause unnecessary skin irritation.

• Scabies should be suspected in infants or children with generalized pruritus of

recent onset and the characteristic eruptions.

• Other family members are usually, but not invariably affected. A history of

scabies in a family member or contact with scabies should be sought out

specifically.

• Scabies diagnosis is confirmed by microscopic identification of the mite, eggs or

scybala.

Dermatoscopy and digital photography are non-invasive and effective methods for

identifying the presence of scabies mites.

TREATMENT - General measures

• Patients must receive detailed information about scabies infestation and

therapeutic options, including the amount of drug to be used and proper

administration.

• Topical treatment must be applied to the entire skin surface, from jawline

downwards including all body folds, groin, navel and external genitalia, as well as

the skin under the nails (especially crusted scabies).

• In adults with classical scabies, treating the face is controversial, but in babies,

the face must be treated, because transmission may occur from breastfeeding.

At any time during treatment, medications should be re-applied if it is washed off

i.e. after hand washing.

• If the treatment is applied by someone without scabies, this person should wear

medical gloves during application.

• Patients with scabies and their close physical contacts, even without symptoms,

should receive treatment at the same time. Prescriptions must be provided for all

household members and sexual partners.

After completion of treatment, patients should use fresh, clean bedding and

clothing. If possible, potentially contaminated clothes and bedding should be

washed at high temperature (>50°C) or kept in a plastic bag for up to 72 hours,

because mites that are separated from the humane host will die within this time

period.

• The use of insecticidal powder or aerosol products should be reserved for

materials or objects that cannot be washed.

Malaria

All four species of Plasmodium are found in Zambia

with 98% of cases caused by P. falciparum both as a

mono- and co-infection with other Plasmodium species.

Mono infections with non-P. falciparum account for

less than 2% of cases and are most commonly caused

by P. malariae.

2,3
2. Clinical features

Fever is the cardinal symptom of malaria. The other

features may include rigors, chills, headache, myalgia,

arthralgia, anorexia, nausea, and vomiting. The features

of malaria are non-specific and can mimic other

diseases like viral infections, bacterial infections (e.g.,

enteric fever) among others.

8–10 Therefore, all clinically

suspected malaria cases should be promptly confirmed

either by microscopy or malaria RDT

4. Treatment of uncomplicated malaria

All confirmed uncomplicated malaria cases diagnosed

by RDT or microscopy should be promptly treated with

effective recommended first line antimalarial medicines

and, currently, the recommended medicines for

uncomplicated malaria in Zambia are ACTs. These

recommended ACTs are Artemether-lumefantrine (AL)

and Dihydroartemisin-Piparaquine (DHA-PQ). DHAPQ preferably must not be used as first line treatment
of

uncomplicated malaria in areas where there is active

DHA-PQ mass drug administration. Both children of all

ages 13–15 and adults with uncomplicated P.

falciparum malaria (except pregnant women in their

first trimester) must be treated with an ACT (see

respective dosage details in Tables 1 and 2).13 An

alternative first line medicine where ACTs are not

recommended is Quinine.

4.1 Treatment of uncomplicated malaria in

pregnancy
4.1.1 First trimester of pregnancy

Treat pregnant women with uncomplicated P.

falciparum malaria during the first trimester with seven

days of oral quinine + clindamycin.

4.1.2 Second and third trimester of pregnancy

Use AL or DHA-PQ in the second and third trimesters

of pregnancy, in the usual adult dose.

4.2 Treatment of mixed infections

For all mixed infections, treat with ACTs as per the

respective ACT drug regimen. Where malaria species

confirmation is not available, treat as P. falciparum.

However, anti-relapse treatment with primaquine can

be given for 14 days if P. malariae is confirmed in a

mixed infection, and in such circumstances wherever

possible check for Glucose 6 Dehydrogenase

deficiency

7. Severe malaria

7.1 Definition

Severe P. falciparum malaria is defined as symptomatic

malaria with evidence of dysfunction in one or more

vital organs (see below) occurring in the absence of an

identified alternative cause and in the presence of P.

falciparum asexual parasitaemia. It may progress from

uncomplicated malaria or be of sudden onset,

particularly in non-immunes.

7.1.1 Features of severe malaria

Clinical features

Cerebral malaria: Impaired consciousness (or a Glasgow

coma score <11 in adults or a Blantyre coma score <3 in

children), multiple convulsions (more than two episodes in 24

hours).

Prostration: Generalized weakness so that the person is

unable to sit, stand, or walk without assistance.

Severe malarial anaemia: Haemoglobin concentration ≤5

g/dL or a haematocrit of ≤15% in children under 12 years of

age (<7 g/dL and <20%, respectively, in adults) with a

parasite count >10 000/μ

Pulmonary oedema: Radiologically confirmed or oxygen

saturation <92% on room air with a respiratory rate >30/min,

often with chest indrawing and crepitations on auscultation.

Metabolic acidosis: Severe acidosis manifests clinically as

rapid, deep, laboured breathing.

Shock: Compensated shock is defined as capillary refill ≥3

seconds or temperature gradient on leg (mid to proximal

limb), but no hypotension. Decompensated shock

(hypotention) is defined as systolic blood pressure <70 mm

Hg in children or <90 mm Hg in adults, with evidence of

impaired perfusion (cool peripheries or prolonged capillary

refill).

Acute renal failure: Urine output of less than 400 mls in 24

hours (less than 1 ml/kg in children)

Severe anaemia, and/or bleeding: Severe normocytic

anaemia (Hb less than 5 g/dl, packed cell volume less than

15%) / abnormal spontaneous bleeding

Jaundice: Plasma or serum bilirubin >50 μmol/L (3 mg/dL)

with a parasite count >100 000/μL

Significant bleeding: Including recurrent or prolonged

bleeding from the nose, gums, or venepuncture sites;

haematemesis or melaena

Haemoglobinuria (black water fever): Characterised by the

passage of dark (Coca-Cola coloured) urine.

Laboratory features

Metabolic acidosis: A base deficit of >8 mEq/L or, if not

available, a plasma bicarbonate level of <15 mmol/L or

venous plasma lactate ≥5 mmol/L or pH of <7.35.

Hypoglycaemia: Blood glucose less than 2.2 mmol/l or less

than 40 mg/dl.

Hyperparasitaemia: Greater than 2% or

100 000/μl in low intensity transmission areas or greater than

5% or 250 000/μl in areas of high stable malaria transmission

intensity.

Renal impairment: Plasma or serum creatinine >265 μmol/L

(3 mg/dL) or blood urea >20 mmol/L.

Hyperparasitaemia: P. falciparum parasitaemia >10%.

7.2 Management of severe malaria

7.2.1 Initial management of severe malaria

If the capacity to manage severe malaria is not available

in the facility, the patient must be referred to a higher

level of care immediately after stabilizing the patient

and giving the first dose of appropriate antimalarial

treatment (refer to section 7.3.1 or 7.3.2). The patient,

especially if comatose, should be managed in a special

observation unit or an Intensive Care Unit and the

following measures undertaken:

1. Confirm the malaria diagnosis.

2. If comatose, manage the airway, breathing,

and circulation (ABC) and position in semiprone or on left side and insert urethral
catheter, nasogastric tube and IV access.

3. Weigh patient (particularly children), if

possible, and calculate dosage per body

weight.

4. Make rapid clinical assessment and look for

signs of meningitis and other conditions.

5. Get blood for glucose, hemoglobin, urea,

creatinine, electrolytes, and others as may be

indicated.

6. Start antimalarial treatment.

7. Start treatment for other complications as may

be indicated and monitor the patient regularly

7.3 Antimalarial treatment

In the general population, injectable artesunate is the

drug of choice for adults and children with severe

malaria.

If injectable artesunate is unavailable, artemether

(intramuscular [IM]) or quinine (intravenous [IV]/IM)

are recommended alternatives.

Following initial parenteral treatment for a minimum of

24 hours, once the patient can tolerate oral therapy, it is

essential to continue with a complete course of an

effective appropriate oral antimalarial.

7.3.1 Injectable artesunate

For severe malaria, IV artesunate is recommended as

described below:

1. Each vial of injectable artesunate must be

reconstituted with 1 ml of sodium bicarbonate

which is normally supplied together with the

vial of artesunate. Shake for 3–5 minutes until

the powder is completely dissolved and the

solution is clear.

2. Dilute with 5 ml normal saline (0.9% sodium

chloride) or 5% dextrose solution.

Caution! Artesunate should not be diluted with

water for injection and the prepared solution

should be used within ONE HOUR of

preparation after which it should be discarded.

3. Dose: Those less than 20 kg should be given

3 mg/kg, while those who are 20 kg and above

should be given at 2.4 mg/kg body weight.

4. Withdraw into syringe and inject intravenously

at a rate of 3–4 ml per minute.

If IV administration is not possible, artesunate may be

given by IM injection as described below:

1. Each vial of injectable artesunate must be

reconstituted with 1 ml of sodium bicarbonate,

which is normally supplied together with the

vial of artesunate. Shake for 3–5 minutes until

the powder is completely dissolved and the

solution is clear.

2. Dilute with 2 ml of normal saline (0.9%

sodium chloride) or 5% dextrose solution.

3. The prepared solution should be used within

one hour of preparation after which it should

discarded

4. Dose: Those less than 20 kg should be given

3 mg/kg while for those 20 kg and above

should be given 2.4 mg/kg body weight.

5. Withdraw into a syringe and inject slowly.

a. The maximum volume to be

administered at each site is 5 ml.

b. The preferred site for IM

administration is the upper, outer

quarter of the anterior of the thigh.

Do not inject artesunate into the buttocks!

Recommended dosing schedule of artesunate

2.4 mg/kg of body weight (or 3 mg /kg body if weight

is less than 20 kg) IV or IM given as follows:

• On admission (time = 0).

• Repeat after 12 hours.

• Repeat 24 hours after the initial dose.

• Thereafter repeat once daily for a maximum of

six days if the patient is still not able to

tolerate oral medication.

5.5. Syphilis

Syphilis is a systemic disease that is contracted mostly during sexual intercourse but

can also be transmitted from mother to child during pregnancy and through blood

transfusion. It is caused by the spirochaete bacterium Treponema pallidum. Incubation

period is about 3 weeks.

a. Early syphilis

Primary syphilis: This is identified by the presence of an ulcer or chancre at the site of

inoculation. A chancre is usually indurated and painless. It forms approximately

21 days after initial exposure to T. pallidum.

Secondary syphilis: Manifestations include but are not limited to a generalized macular

or maculopapular rash mostly affecting the trunk but may also involve the palms and

soles, lymphadenopathy, and oral and genital mucous patches (condyloma lata), loss of
hair. Patients often give a history of a chancre or may have a persisting chancre.

Early latent syphilis: Characterized by positive serological tests for syphilis, with a

history of symptoms suggestive of infection or a positive syphilis contact within the

preceding year.

b. Late syphilis

Late latent syphilis: Positive serological test for syphilis with no history of symptoms or

contacts in the past one year.

Tertiary syphilis: Characterized by gumma (granuloma resulting from endarteritis)

which may affect the skin and bones. Cardiovascular syphilis may manifest as aortitis

and aortic aneurysm. Neurosyphilis may occur 10 to 30 years after initial infection and

may include tabes dorsalis and general paralysis of the insane.

Diagnosis

Direct detection methods for T. pallidum

• Dark-field microscopy

• Direct fluorescent antibody (DFA) test

• Nucleic acid amplification tests (NAATs)

Serological tests for syphilis

Treponemal antigen tests (Specific to syphilis)

Test Application

Enzyme

immunoassay (EIA)

Sensitive and specific screening test

Positive from primary infection onward

IgM-EIA Improves detection of early primary infection

FTA-abs Standard confirmatory test

TPHA or TPPA Can be used both as standard screening and confirmatory tests.

More practical than the FTA-Abs.

Cardiolipin antigen tests (Non-specific to Syphilis)

VDRL Best used for CSF specimen

RPR Widely used screening test

Most applicable and available laboratory method in Zambia

RPR or TPHA can be used as screening tests. RPR in non-specific, therefore a positive

RPR should be followed by a confirmatory TPHA. Treponemal antigen tests such as

TPHA usually remain positive for life, even after treatment. Therefore, a positive TPHA

may mean either current infection or previously treated infection. RPR titers can be

used to monitor the course of disease and treatment, as the intensity of reaction

usually decreases in late disease or after therapy. A 4-fold decrease in non-treponemal

titres within 6-12 months after therapy is regarded as successful treatment.

Treatment

Recommended syphilis treatment regimens

Stage Drug Regimen

Primary and secondary

syphilis

Benzathine penicillin G 2.4 million units IM in a single dose

Early latent syphilis Benzathine penicillin G 2.4 million units IM in a single dose

Late latent syphilis Benzathine penicillin G 7.2 million units total administered as 3 doses of

2.4 million units IM each at 1-week intervals

Tertiary syphilis

(excluding neurosyphilis)

Benzathine penicillin G 7.2 million units total administered as 3 doses of

2.4 million units IM each at 1-week intervals

Neurosyphilis Aqueous crystalline

penicillin G

18-24 million units per day, administered as 3-4

million units IV every 4 hours for 10-14 days

Penicillin allergy and other alternative drugs

Doxycycline 100mg BD PO x14days (primary and secondary syphilis)(8)

Azithromycin 2g PO stat (primary and secondary syphilis)(9)

Ceftriaxone 1-2g OD IM or IV for 10-14 days (failure rate is high for neuro-syphilis) (10

Procaine penicillin 2.4 million units OD IM plus Probenecid 500mg QID PO both for 10-

14 days (Alternate regimen for neurosyphilis)

Pregnant women who are allergic to penicillin should be desensitized and treated with

penicillin. HIV-infected individuals should be treated in a similar manner as those that

are HIV-negative. However, HIV-positive individuals should undergo a careful

neurological examination to rule out neurosyphilis.

5.6. Congenital syphilis

Congenital syphilis is syphilis present in utero and at birth. It occurs when T. pallidum

is transmitted transplacentally or at birth.

Clinical features

Early (0 to 2 years old): Newborns may be asymptomatic and only identified on

routine prenatal screening.

Late (≥ 2 years old): Some of the commonest clinical features include Hutchinson's

teeth, keratitis, frontal bossing, deafness, saddle nose, swollen knees, and saber shin.

Treatment

Aqueous crystalline penicillin G 100,000-150,000 units/kg/day IV in 2 to 3 divided

doses for a total of 10 days. (preferred)

OR

Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days

Complications

Symptomatic newborns, if not stillborn, are born premature, have poor feeding with

rhinorrhoea, with hepatosplenomegaly, pneumonia, skeletal abnormalities, and

pemphigus syphiliticus.
Gonorrhoea

Gonorrhoea is caused by Neisseria gonorrheae which is exclusively a human pathogen

and almost exclusively sexually transmitted. It causes urethral discharge in men and

cervical discharge in women.

Clinical features
Purulent male urethral discharge

Men

• Median incubation period is about 3-6 days

• Incubation period of gonorrhoea is usually shorter than that of non-gonococcal

urethritis (NGU) caused by chlamydia

• Purulent or mucopurulent urethral discharge in 80% of cases

• Dysuria

• Rectal infection is usually asymptomatic may cause anal discharge or pain in around

10% of cases

• Pharyngitis may be present in both and women (15)

Women

• Up to 50% of all women with gonorrhea are asymptomatic.

(15)

• Incubation period in women is longer than in men.

• Symptoms are non-specific and cannot be distinguished from those of other lower

genital-tract infections.

• The most common symptom is a change in vaginal discharge, originating from an

infected endocervix. Two major diagnostic signs of cervicitis include: 1) purulent or

mucopurulent endocervical exudates visible in the endocervical canal or on an

endocervical swab specimen and 2) Sustained endocervical bleeding easily induced by

gentle passage of a cotton swab through the cervical os.

• Urethritis, purulent urethral discharge, and/or dysuria may or may not be present.

• Gonococcal proctitis and pharyngitis may also be seen in women.

Diagnosis

1. Microscopy: Gram-negative intracellular diplococci seen on examination on direct

microscopy in Gram-stained samples of discharge collected from the urethra or

rectum or endocervix from women.

2. Culture: Currently regarded as the standard method for diagnosis of infection and

allows the testing for antibiotic susceptibility and detection of resistance

patterns.

(16)

3. Nucleic acid amplification tests (NAATs): NAATs have very high sensitivity and

specificity compared to microscopy and culture.

(16)

4. Gonococcal antigen test: may be useful if other detection methods are not

available.

Treatment

Recommended regimens

Ciprofloxacin 500mg PO Stat PLUS Azithromycin 1g PO Stat

OR

Ceftriaxone 250mg IM Stat PLUS Azithromycin 1g PO Stat*

OR

Cefixime 400mg PO Stat PLUS Azithromycin 1g PO Stat

Alternative regimens

Cefotaxime 500mg IM Stat PLUS Azithromycin 1g PO Stat

* NB: Adding Azithromycin not only improves the efficacy of treatment but also

treats C. trachomatis co-infection and reduces drug resistance. If Azithromycin is

not available, Doxycycline 100mg bd PO for 7 days can be used.

* All women with history of contact with symptomatic partners should be treated.

Treatment for gonococcal ophthalmia neonatorum

Ceftriaxone 25-50mg/kg IM or IV Stat, not to exceed 125mg

Complications in adults

• In females: pelvic inflammatory disease, ectopic pregnancies, infertility, chronic lower

abdominal pain, miscarriages, disseminated gonococcal infection.

• In males: Prostatitis, urethral scarring and stricture, infertility, epididymo-orchitis,

disseminated gonococcal infection.