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Viral infections.
Rabies
In Africa, rabies is contracted from an infected dog, fox, mongoose or jackal. Rabies is a notifiable disease.
Pre-exposure prophylaxis:
- For high-risk individuals such as vets and SPCA workers.
- One dose of anti-rabies vaccine is given IM (deltoid) on day 0, 7, and 28. (Give a dose, repeat at 1 week and then again after 3 weeks). A booster dose should be given every 1-3 years.
- A single ‘dose’ varies with manufacturer and usually will be between 0.5 and 1 ml.
- If adequately vaccinated individuals get a suspect bite, give one dose of vaccine, and repeat after three days. (Days 0 and 3.) Such persons shouldn’t need immunoglobulin.
Management of a non-immunised person bitten by a possibly rabid animal.
- Immediate management – wash the wound thoroughly with soap and water.1
- Grade the severity of contact with a careful history and examination.
- For minor contact (reliable history of no more than licking of intact skin) reassure.
- For anything involving minor skin injury give vaccine but not immunoglobulin. (1 dose of vaccine IM (into deltoid, NOT buttock) on days 0, 3, 7, 14 and 28. If it is more than 48 hours since exposure, give a double dose on day 0.)
- If blood was drawn or there was mucous membrane contact, give both vaccine and immunoglobulin. (1 dose 20 I.U./kg of human anti-rabies immunoglobulin infiltrated around the wound or deep IM if not enough space.)
- Don’t forget to clean the wound! (5 minutes of soapy water or chlorhexidine, then apply povidone iodine). Give 0.5 ml of tetanus toxoid. Add an antibiotic if thought necessary for suspected bacterial co-infection.
- No matter how long since the exposure (up to 60 days!) it is probably still worth giving the vaccine if the exposure was significant.
Management of a patient with suspected rabies.
- The incubation period is 20-60 days. There is a non-specific prodrome, often paraesthesiae at the bite site, then an episodic hyperactive psychotic state.
- It can also present as paralysis with no agitation. Hydrophobia is not always present but is startlingly characteristic – offer a cup of water and observe.
- Sedate heavily – this is usually a fatal illness, and the four or five patients reported as having survived were nearly all left with severe neurological sequeli. One survivor was treated with a combination of ketamine, midazolam and amantadine.2
- Gloves, masks and goggles for health personnel, and post-exposure prophylaxis for those with mucous membrane or transcutaneous contact with secretions.
- Take saliva in primary, secondary and tertiary containers (e.g. sputum container in a sealed plastic jar in a box. Send to the National Institute for Communicable diseases. (Tel 011 386 6000.)
- This is a notifiable disease. If a post-mortem is needed, take special precautions!
Management of an animal suspected of being rabid.
Contact the local state vetinarian who is responsible for tracking down the animal.
If the animal is well and behaving normally and can be confined, the vet will observe it for ten days. Otherwise it should be killed (preferably by the vet rather than the police who are sometimes unaware of the effect that a neatly placed high velocity projectile has on subsequent delicate attempts at CNS histology).
Disseminated herpes
Herpes involving the mouth is well recognised; less well known is the rare disseminated form which can present with features of a DIC, fever, and a hepatitis. Serology is helpful once considered, but usually only makes the diagnosis retrospectively. In view of the high mortality, early consideration should be given to treatment with intravenous acyclovir in a dose of 5-10 mg/kg/dose 8 hourly.
Zoonoses and haemorrhagic fevers
(All are notifiable diseases)
Marburg and Ebola
Marburg and Ebola are filoviruses that cause a very similar illness, with headache, fever (>38C) and back pain after an incubation period of 10-21 days. Diarrhoea, vomiting and a measles-like rash with conjunctivitis may be present. There is an appropriate travel history. Thrombocytopenia and biochemical hepatitis occur. Diagnosis is by PCR of serum looking for the antigen, or by various antibody tests. Treatment is supportive in an isolation facility. Mortality about 40%. The recent (2014) West African outbreak has raised awareness of the condition in returning travellers, and careful contact precautions apply. It is transmitted by blood and body fluids, not aerosol: contact your local infection control staff about correct protective clothing and isolation procedures for suspected cases.
Congo fever
Same incubation period and clinical features as tick-bite fever, except that the haemorrhagic component is very marked. Can present with acute abdominal pain that is mistaken for a surgical emergency. The ‘classical’ patient had features of fever plus haemorrhagic manifestations, sometimes with pharyngitis and conjunctivitis. The illness is of short duration and rapid progression, and there is usually some history of contact or possible contact with either a tick or another person with the illness. There may be either a leukopenia or a leukocytosis, and thrombocytopenia is characteristic. LFTs often moderately elevated. Consider severe septicaemia, tick bite fever, leptospirosis, measles, herpes, and perhaps even leukaemia/aplastic anaemia/TTP.
Management is supportive – blood products as needed plus barrier nursing.
Contact the Special Pathogens Unit of the National Institute for Communicable Diseases (Tel: 011 386 6000, Outbreak hotline 082 8839920.)
SARS
SARS (Severe (or Sudden) Acute Respiratory Syndrome) is a respiratory illness due to a coronavirus, which first came to attention in early 2003. Mortality ranges from 3-50% depending on age, and it is highly infectious, with attack rates as high as 50%. With rapid air travel, suspected new cases can present anywhere. Most of current management is dictated by information on Covid-19
MPox
See here: https://medeval.co.za/a-pox-upon-it-mpox-overview/
Covid-19
– see separate section by clicking here: Covid-19 issues