Back to Reality....

It's now been 7 weeks since I returned from Ho Chi Minh City to Oxford. From hordes of motorcycles to hordes of students. From scorching dry heat to damp cool.
It's been easy to return to normality, to taking clean wards and air-conditioning for granted. The green restraints which tied most patients to their bed frame have disappeared, replaced by a large, robotic arm which emerges from the wall, carrying an all-in-one television, phone and computer to the patient's side. Lunch is handed out three times a day, not by patients' relatives but by Carillion staff in blue t-shirts. Curtains are drawn around the bed during conversations and examinations, instead of being rolled up and out of the way. The emaciated have been replaced by the morbidly obese.

I hope the posts in this blog have been interesting, to both the medics and especially non-medics out there. If you're a medical student thinking ahead to your elective, I hope this will encourage you to travel to somewhere very different to what you're used to and see things you may never see again. Vietnam has certainly been an amazing experience for me, from both a human and a medical perspective. I hope you will also have the opportunity to visit this beautiful country one day.

Needles in a smelly haystack

I've been spending quite a lot of time recently in one of the Clinical Research Unit's labs. The research is aimed at understanding more about the epidemiology of Fascioliasis, a parasitic disease which is present worldwide. Fasciola hepatica, and its cousin Fasciola gigantica, are two trematodes (parasitic flatworms) which can accidentally infect humans. They spend their childhood and teenage years in freshwater snails; once they've matured and are ready for the trials of adulthood, they leave the snails and set up camp on aquatic vegetation. There they wait for unsuspecting mammals, such as sheep or cows, to eat the vegetation. Once inside their new host, they spread through the gut and biliary system, where they can mature further and begin to produce eggs which are shed in faeces. The faeces contaminate freshwater ponds, which contain snails, and so the cycle is complete.
Humans blunder into this cycle by eating the aquatic plants from the pond (how clean is that watercress in your sandwich?). Cue abdominal pain, fever, nausea and vomiting and a raft of allergic symptoms. The infection can persist for months until the diagnosis is considered and confirmed; subsequent treatment is with a course of triclabendazole.

Back to the lab. Does F. hepatica or gigantica cause most of the human disease in Vietnam? How much Fasciola is there in the local ruminant population? To answer these questions, we're sifting through the animals' faeces in search of Fasciola eggs, and then trying to extract DNA from them to identify the species. This is actually a lot more fun than it may sound, and is a good way of learning about common molecular biology techniques. Hopefully we will have some results soon; these should help us better understand the disease, eventually allowing us to treat it earlier and more efficiently.

Cholera, really?

On our way past Ward D, Dr Lan rushes up to meet us. "We have a case of cholera!" - she beams at us. The excitement among this pack of infectious disease docs becomes palpable. We ignore an imminent ward round and make our way to see the patient. Images of an exhausted, dehydrated man enter my mind; I cannot help but think of those beds I saw outside the ICU, with a strategically-placed hole betraying their role. I am about to witness one of the great killers of the past 200 years, the plague of urbanisation and poor sanitation, the very disease which led John Snow to father epidemiology in the streets of 1850s' Soho.


We must have entered the wrong room. Sitting on the bed, a colourfully-dressed young lady looks at us, smiling. If we are in the right room, then surely this must be a relative, come to see her dying husband or brother? Not so. This patient came in five days ago, complaining of severe diarrhoea. Within 24 hours of admission, Nature was calling over ten times a day. She became dehydrated and required aggressive fluid resuscitation. Stool samples grew Vibrio cholerae. And then that was it; she just got better. Today she looks absolutely fine and is ready to go home.

The microbiologists are not entirely convinced. They weren't able to isolate that many bacteria from this patient and so we will probably never have a satisfactory answer. Be that as it may; I'm still surprised by how disappointed I was to see such a well-looking patient today.

The Mekong Delta: a public health nightmare

The Mekong Delta is a vast and beautiful expanse of waterways in southern Vietnam. Having travelled over 4,000 kilometres from China, taking them through all the countries of South-East Asia, the waters of the Mekong spread out over much of the land south of Ho Chi Minh City. Arriving by night, each river crossed makes me think of the next tentacle which a dark octopus might be trying to block our route with.
By day, a vibrant, bustling hive of activity takes shape as the sun rises. Everybody here owns a boat. For some it is also their home. For all it is their way of making a living, taking them and their wares to the many floating markets of the Mekong. There are some laden with mangoes, bananas, watermelons or pumpkins; ice or rice; clay hearths or charcoal; and bread or pho, to cater for the morning munchies.
The river however is much more than an aquatic road to the nearest market. Most of the homes here have a back door which leads straight out onto the brown, murky Mekong waters. This is where clothes are washed, pots and pans are rinsed and litter is discarded. Children play in the lukewarm waters while teenage girls clean their bicycles nearby. A man lowers a bucket into the shallows to collect a little water to brush his teeth with. A young woman crouches down on a ledge, washing her long, dark hair in the river. The Mekong is everything to the people here: every activity involves its waters at some stage.
Drifting along in a small boat, I cannot help but think of all the other creatures which populate this river. Countless bacteria, viruses and parasites thrive in the warm, humid environment provided by the Mekong, repeatedly introduced there by humans and other animals. Hepatitis A, typhoid fever, cholera.... the list is long and frightening.
The waters of the Delta are a public health nightmare. The question is, how can one go about changing some of the behaviours of those whose lives depend on this river? Where should a benevolent Health Minister start? Try as I might, I cannot imagine that the situation here could change until there is a realistic alternative way of life for all the people who are born on the Mekong and only know how to survive thanks to its waters.

Avoid the snails, they're fresh.

One of the attractions of infectious diseases is that there is usually a high turnover of patients. As a general rule, treatment brings about a rapid improvement and patients can return home within a few days, even if they will be receiving on-going treatment for a longer period. My experience at the Hospital for Tropical Diseases has reflected that so far: most patients have been on the wards for only two or three days.
The Viet Anh (Vietnamese-British) ward specialises in neurological infections however, and as such defies the rules. Some patients arrived here before me and unfortunately it looks like they will stay here long after I've left. One of them hasn't moved since my first ward round. He lies on his back, eyes wide open, a ventilator and tracheostomy apparently keeping him alive. The only sign of life is the perpetual twitching of his left cheek, which causes a little foam to form at the corner of his mouth.
A few months ago, he and his twin brother were working in a field outside of Ho Chi Minh City. Pausing for lunch, they noticed the pond nearby was full of snails and didn't think twice: a few raw gastropods and back to work. Unfortunately, the snails were carrying the roundworm Angiostrongylus cantonensis. This parasite usually lives in the lungs of rats, but regularly makes excursions to their gut. Once excreted into the open world, it then relies on snails and slugs to ingest it so that it can develop into new, fully-infective larvae which can colonise new rats.
As is often the case with such worms, humans are only an "incidental host" (see Half a Brain). They become infected by eating raw or under-cooked snails and slugs, or vegetables contaminated by them. Having invaded a new host (be it a human or a rat), Angiostrongylus travels first to the brain and causes an inflammatory reaction which is characterised by the presence of a specific type of white blood cell: this is eosinophilic meningitis, and this is what brought our two brothers into hospital.
Though they both suffered from headaches, nausea and vomiting, neck stiffness and the occasional seizure, only one of them had read the textbook. He got better after a fortnight, and returned home. His brother, however, slipped into a coma and he is still there now. Most patients with eosinophilic meningitis make a full recovery; it is extremely rare for it to cause brain damage as it has in this case.
At this stage, after such a long coma, there is little cause for optimism. He may yet make a miraculous recovery, but it is unlikely. His family will eventually have to decide whether they wish to keep paying for him to receive supportive treatment in hospital, or whether they would rather he came home and were released from his bodily prison.
His brother, with whom he shares so much, reminds us that when two similar people are infected with the same parasite, the outcome can still vary enormously. We still have a lot to learn about the factors which dictate who will be the lucky ones. And we still have a mountain to climb in order to prevent poor, hungry people from eating a quick, easy and free lunch.

X-rays à l'ancienne

As a medical student, you are often asked to "take a look at this X-ray". Sitting in front of the computer, mouse in hand, you quietly begin to scan the image in front of you for abnormalities. If the doctor has asked you to look at it, there must surely be something there to see. But you see nothing. Fortunately, you have a few tricks up your sleeve: a flick of the mouse-wheel and the image is magnified; a click-and-drag changes the contrast to further increase your chances of success. Still nothing. A few clicks and the patient's last two X-rays appear on-screen for you to compare. Expectant silence from the crowd behind you. Finally, there it is: a subtle fleck you had not so much ignored as simply not seen; suddenly the diagnosis becomes obvious.
Nowadays we're not often exposed to old-fashioned X-ray films, so it's easy to forget that this is a very privileged and modern way of looking at radiographs.

The scenario here is quite different. The X-ray comes out of a large brown envelope which is carried around by the junior doctors. Most of the rooms don't have a light-box, so you have to hold the film up to the light. This is harder than it sounds: too much light and you find yourself gazing through the image at the patients and doctors who are watching you. Not enough light and you simply can't make out anything. Try to ignore the fingerprints and the patient ID slip which has conveniently been stapled to the film. No zoom, no contrast setting, no integrated ruler; it's just you and the film, locked in a staring contest. The whirr of the ceiling fans is eventually interrupted when you accidentally loosen your grip on the film and it noisily flops down, lifeless.
When the decision to start TB treatment rests on your interpretation of the X-ray, you suddenly wish you had a dark room and a high-definition monitor to call upon.

The Glamour of Microbiology

Microbiology is one of those subjects which cause a double eyebrow-raise at dinner parties. "Oh! that must be interesting" is the usual reply, the emphasis revealing that there really isn't a follow-up question available for this area. No, microbiology is no Neurosurgery or Cardiology. No eighteen holes at the week-end for those who gaze down microscopes at Gram stains. But it can be fun nonetheless.
Nha Trang is a small city on the coast of South Central Vietnam. If you stroll down Tran Phu along the beach, you eventually come to the Institut Pasteur, a site of great importance in the history of infectious diseases. In 1891, a young Frenchman by the name of Alexandre Yersin set foot in Nha Trang and instantly fell in love with the place. Flanked to the east by the dark, turquoise waters of the South China Sea, and to the west by steep, green mountains, it isn't difficult to see the attraction. A promising scientist, Yersin had left Europe and the shadow of a certain Louis Pasteur in search of adventure. He joined the French Navy as a doctor and his first mission took him to Indochina.
Realising the excellent opportunity for microbiological research which the Far East offered, Yersin set up a modest laboratory in Nha Trang. Within a few months, an epidemic of bubonic plague hit Hong-Kong and Yersin decided to join the race to discover the organism responsible for the Black Death. The germ theory of disease was still in its infancy: what a coup it would be to unmask a disease which had claimed hundreds of millions of lives for over a thousand years! While several scientists looked for the bacteria in patients' blood, Yersin instinctively assumed that he would find it in the buboes, those swollen, necrotic lymph glands which give the disease its name. He struck gold: in 1893 he identified and described the microbe responsible, which has subsequently been named Yersinia pestis in his honour.
Back in Nha Trang, in the newly-founded Institut Pasteur, he set about creating a serum to cure the disease in the same way that Pasteur had done for rabies. He was successful again and his discoveries were able to immediately save thousands of lives. Not one to rest on his laurels, Yersin turned his attention to agriculture, developing strains of Rubber and Cinchona tree which would thrive in Vietnam, providing both rubber and quinine. He founded the Ecole de Médecine in Hanoi and also went on map-writing missions, discovering a route south to the Mekong delta and west to the mountain resort of Da Lat.
Yersin made Vietnam his home and never left. At his death in 1943, thousands of Vietnamese attended his funeral, and a Buddhist shrine and pagoda were erected by his tomb near Nha Trang. Still today, locals come to pay homage to a man who they consider gave his life and work to his adopted land.

Microbiology: no golfing week-ends, but potentially a prolific career in the sun and the eternal gratitude of an entire nation.

A Missed Opportunity

In the ICU today, a young girl lies unconscious. Oblivious to the crowd of doctors in the room, she is being kept alive by a ventilator and a feeding tube. She looks very peaceful, as sleeping children often do, but this belies the events going on in her head.
About 14 days ago, she was bitten by a mosquito of the Culex family. Young girls are not normally the target of Culex mosquitoes: they tend to go more for pigs and wading birds, which are the main reservoirs for Japanese Encephalitis Virus (JEV). However, every now and then, humans get bitten. This particular mosquito was carrying JEV and unwittingly transmitted it to our patient. She subsequently developed a fever, headaches and became nauseous. She fitted and then began to lapse into a coma. And now she is in our ICU, fighting for her life.
Only 1% of JEV infections cause encephalitis, accounting for some 50,000 cases annually. Unfortunately though, the outcome when it happens is terrible: 30% die; 30-50% survive, but with irreversible brain damage; and less than 30% make a complete recovery. The only antiviral treatments which exist have been shown to be useless in Japanese encephalitis - all we can do is wait and hope that she is in the minority which pull through.
It is terrible to see a young girl who may well die or be left brain-damaged by a childhood infection. What makes it worse is that Japanese encephalitis is a preventable disease. While the two vaccines offered to travellers are not ideally suited to mass immunisation programmes in the region, a Chinese vaccine has shown great promise. Several trials have shown it to be particularly effective in children, who are the main victims of JEV. Why it has not yet been incorporated into regional vaccination programmes is not clear to me, but it certainly appears to be a missed opportunity.
There are plenty of excellent vaccines out there which have the potential to prevent millions of childhood deaths every year. Most of them are not expensive to produce: the main challenge is making them available to the people who need them, and ensuring that as many people are immunised as possible. At the moment it seems we're investing far more in inventing new treatments than we are in using those that already exist.

Half a Brain

Some people (not scientists) say that we only use half of our brain. While this sounds impressive, I'm not sure what it means - it certainly goes against what I learned in neurology. Nonetheless, it can be surprising to see just how much disruption this soft, watery organ can withstand.
Our patient is a young, HIV-positive man. Like so many of the HIV patients I've seen here, he isn't on any anti-retrovirals. He's come in to the hospital because of three weeks' headaches, which are getting worse. He's also got a fever, and has vomitted on a few occasions. There's no neck stiffness, no lymph nodes and neurologically he's intact. In fact, looking at him, there's very little to suggest anything's wrong. He is well enough to face the ambulance trip across Ho Chi Minh City to the nearest MRI centre: cue sirens and unnecessarily hazardous driving.
As medical students, when reading scans, we're always taught to start by checking the identity of the patient. It would be tempting to assume that the MRI which has just been put up on the light box is of a different patient, but it isn't. The left half of his brain is distorted by a large, ring-enhancing lesion surrounded by oedema. A smaller lesion lies in the occipital lobe. It is hard to believe that this is the brain of the young man who was talking to us earlier and later went out for a walk.

While TB and primary CNS lymphoma are possibilites here, this is toxoplasmosis. The intracellular protozoan parasite Toxoplasma gondii probably infected our patient many years ago, before he had AIDS. His immune system controlled the infection but parasite cysts remained dormant in his muscles and other organs. As a result of HIV, Toxoplasma became reactivated and invaded his brain in dramatic fashion.
About 20% of the world's population has been infected with Toxoplasma, usually as a result of eating under-cooked meat. Our fluffy feline friends are the main hosts for the parasite, innocently fertilising gardens and fields with it. Farm animals then eat it, or we forget to wash our hands, and thus become infected. While most people will experience only a flu-like illness, foetuses can die from toxoplasmosis, which is why pregnant women have to be particularly careful when cooking meat.
As with many parasitic diseases, humans are just an accidental host in the organism's life-cycle, and one which doesn't do it any good. But as our patient demonstrates, such accidents can have devastating effects on vulnerable patients. Fortunately, six weeks' antimicrobials will restore his brain's integrity and he will soon be back to normal. Well, as normal as can be with untreated AIDS.

Twitch, twitch, twitch.

It's International Women's Day today: all the women in the hospital are greeted with a rose and, if they're lucky, a lollipop. I don't recall anyone ever celebrating Women's Day in the UK, but then roses are far more expensive there.
Twitch. In the ICU, one woman is not spending Women's Day as she might have hoped. A few days ago, (twitch), she went to the dentist to have a cavity treated. Somewhere along the way, she became infected with Clostridium tetani, which, as its name suggests, is the bacterium responsible for causing tetanus. Twitch. Painful spasms in the muscles of her jaw brought her to the hospital. Now, after a hefty dose of sedation and muscle relaxants, she is beginning a long and dangerous hospital stay (twitch). She is at very high risk of developing a respiratory infection which, given the frightening rates of antibiotic resistance here, would surely be a death sentence. Despite the doctors' best efforts (twitch), uncontrollable spasms still shake her body every few minutes. You cannot help but look on, waiting for the next one. Twitch. If it wasn't for the sedatives, she would be in agony.

The Clostridium family is a nasty one, responsible as it is for tetanus, gas gangrene and botulism. C. tetani loves a dirty wound and, given the opportunity, will invade in a matter of days. It produces a toxin which specifically targets the central nervous system, impeding the normal mechanisms which regulate muscle contraction. The result is violent muscular spasms, typically starting with the masseters, leading to 'lock-jaw'. The expression risus sardonicus (sardonic smile) is still sometimes used to describe the snarl produced by the disease. (Interestingly, the word 'sardonic' apparently alludes to a Sardinian plant which, when eaten, would produce convulsive laughter and death - so much for herbal medicine). The other characteristic feature of tetanus, the arching of the back or opisthotonus, is more commonly seen in infants than in adults.

Fortunately, tetanus is very preventable. The vaccine probably confers ten years' protection, and it is thought that after three or four jabs there is life-long immunity. In Vietnam, 85% of the population is immunized; however that leaves nearly 13 million unprotected individuals. As the disease does not prevent subsequent re-infection, patients are always followed up with three jabs. Hopefully, with improving vaccine coverage, tetanus will become as rare in Vietnam as it is today in Europe, and patients such as this one will be able to celebrate Women's Day without all the twitching.

TB or not TB?

I've always thought of tuberculosis as a disease of the lungs. I won't pretend that it's because of La Traviata and her persistent coughing which punctuates Puccini's work. Even after three and half years of medical school, I couldn't help associating TB with coughing, weight loss and a few other symptoms.
Of course, this isn't wrong: the lungs certainly are a site of predilection for Mycobacterium tuberculosis. It likes to set up camp there and hibernate for years, sometimes a whole lifetime. But despite this affinity for the draughty recesses of the chest, TB also enjoys going for a wander elsewhere. The spine, the kidneys, the eyes: no sites are really off limits for this bacterium if the conditions are right.
The conditions are definitely right in this patient. He contracted HIV many years ago and has not been receiving any antiretrovirals. Slowly, but surely, the virus has gained the upper hand over his immune system. Today, his body is essentially a very badly defended shelter for whichever micro-organism might choose to invade.
He came in to the hospital because he was having difficulty walking. On examination, he is weak all along his right-hand side. He has swollen lymph nodes throughout his body, along with headaches and fever. This picture is typical for toxoplasmosis, but the doctors here are convinced it will turn out to be TB in the brain. There's so much of the disease around, the investigations will probably prove them right.
A few weeks ago I would never have associated TB with hemiplegia, particularly if the patient didn't have any chest symptoms. Perhaps someone could have guided me there with some leading questions, but the two things just weren't linked in my mind. Having now seen nearly a dozen cases of TB meningitis, I'm starting to realise that most things could be due to this disease.

Scared of Air

The first thing I noticed about this patient was how well he looks. In an ICU full of emaciated, jaundiced and comatose patients, he stands out because he seems fine. He's fully conscious and notices us as we come to stand at his bedside, looking down at him. He begins to talk to Dr Nguyen - perhaps he's asking how much longer he has to stay here. He smiles and laughs, and then returns to his thoughts while we examine him.
His bed is oddly placed within the ward. He's not lined up with the other patients in the bays; instead he lies in the middle of the ICU despite there being ample space elsewhere. We probe Dr Nguyen for answers. "Afraid", he says, in very broken English. "Afraid, er, of... of wind". This doesn't make sense to me - I must have misunderstood. But Dr Nguyen illustrates the point: taking his notepad in his hand, he waves some air into the patient's face. Suddenly, everything changes. A terrified look is in the patient's eyes, and he draws in a sharp breath, as if he's seen a ghost. A few seconds of wide-eyed stares; and he's back to normal. Looking calmly around the bed, breathing quietly. He asks Dr Nguyen another question.
The look of terror that overcame our patient is probably matched only by the look of amazement on my face. "He's afraid of air?" I ask, still skeptical despite the obvious demonstration. Dr Nguyen repeats the process. Again, the patient gasps as soon as the air reaches him. The fear in his eyes is unlike anything I've ever seen before. And then it's gone again, melting away almost instantaneously.
That's it. That's all there is to see in this patient. He was brought in to the hospital this morning, because of his strange behaviour. His bed is strategically placed to avoid the drafts from the two large air conditioning machines: they would be unbearable for him. On questioning, it emerges that he was bitten by a dog two months ago.

Fear of air and water are pathognomonic for rabies: no other disease produces these symptoms. And while he may look well between the flashes of terror, he will be dead in a matter of days. Just as there is no doubt about the diagnosis, there is no doubt about the outcome: once symptoms appear, the mortality rate is 100%. An urgent course of vaccinations after the bite might have saved his life, but it is too late now.
For the past two months, the virus has been slowly making its way through his nervous system and up to his brain. Once there, the virus begins to replicate and then spreads back out via the neurones to most organs including the heart, eyes and kidneys. Signs and symptoms then begin to appear, including paralysis, confusion, agitation and the tell-tale phobias. The salivary glands are hijacked, churning out millions of virus particles in the hope of infecting a new host.
Patients with rabies don't usually stay in the hospital very long. Once the diagnosis has been explained to the family, patients are usually taken home: there is no point paying for medical treatment when it can ultimately do nothing for the patient.
Before leaving the ward, I take a last look at him. He still looks very well. The calm before the storm.

An Ancient Foe

Two days, two patients. The first is middle-aged and looks uncomfortable lying on his back. He was brought in unconscious and feverish. His hands are shaking despite the green restraints tied around his wrists. Lots of patients in the hospital have restraints such as these: there are no sidebars on the beds and hospital staff worry that they may fall off. Back to our patient. He has a big liver, and his skin bears an appropriate yellow tinge. I begin to list in my mind the viruses, bacteria and fungi which can cause liver failure.
Our second patient is much older, and much sicker. Similarly restrained for his protection, he is fast asleep, snoring, seemingly oblivious to the anxiety he is causing the pack of doctors gathered around his bed. An NG tube feeds him, while a ventilator attached to his tracheostomy breathes on his behalf. Despite the big liver, this patient isn't yellow. Admitted with fever, cough and difficulty breathing, he was found to have a bad chest infection; subsequent tests reveal the space around his lungs has filled with blood. His chest X-rays give us plenty to talk about.

Despite my list of microbes which target the liver, I'm wide of the mark (a pattern is emerging). Both alcoholic, these patients' ailments are self-induced. Their livers have suffered for years and are finally giving in. Unfortunately, I don't think a transplant is on the cards.
In the Hospital for Tropical Diseases, I could be forgiven for thinking that every presentation has an infectious agent behind it. But the source of both these patients' problems is not a tropical bug, it's a bottle.

What's in a name?

An "isolated" side-room, but only by name. The transparent window panes and the open door do little to seperate this patient from the rest of the Intensive Care Unit. We sidle in one by one, until there are about a dozen of us around the bed. The discussions begin.
A dark, vertical line across her abdomen confirms that she was pregnant until three days ago. Having lapsed into a coma shortly after delivering, she has yet to see her baby. She was admitted to the hospital two days earlier, complaining of fever, headache and generalised aches. Now she is unconscious, and bleeding. In fact, she hasn't stopped bleeding since giving birth. 15 units of blood, three times her circulating volume, have been transfused. But we are only buying time, and at a very high cost.
The problem with dengue is that it can make you bleed for a week, sometimes two. That's an awful lot of blood. It may well be that she's unconscious because of a bleed in her brain as well, but an ambulance transfer to a scanner, when you're connected to a ventilator and being transfused, is not a feasible option. It's far from obvious what the next step should be.

Out of the two crossed conversations taking place, I try to block out the Vietnamese and concentrate on the English. My mind invariably drifts back to the fascinating sounds and intonations of the Vietnamese, which try as I might I cannot yet reproduce; the only word I can make out is "dengue". Like the mosquito-borne virus it describes, the word has spread from the African continent (dinga, Swahili for "cramp") to most of the tropics. Some say that the Swahili origin was influenced in the West Indies by the Spanish dengue, meaning "prudent" - a reference to the gait adopted by sufferers. The muscle and joint pains which account for this gait have also earned dengue the nickname "break-bone fever".
Today dengue accounts for 50 to 100 million infections every year. Repeated infection can lead to life-threatening dengue haemorrhagic fever - while our patient only has a milder form of this bleeding disorder, the coincidence with her labour could yet prove fatal. There is no cure for dengue: all we can hope to achieve is prevention, hopefully through vaccination.

If and when dengue becomes a rare disease of Ancient Times, its name will perhaps serve to remind us of the suffering it caused for centuries.

Progress towards a dengue vaccine (Webster, Farrar and Rowland-Jones)

All Hail Penicillium

We are all familiar with the story of Alexander Fleming, returning from holiday in 1928 to discover his S. aureus culture plates had been contaminated. An assistant, carelessly, had left a window open in the laboratory; Penicillium chrysogenum, no doubt sensing an opportunity to become famous, went on a rampage, killing countless bacteria. Fleming realised what had happened and since then penicillin has saved innumerable lives.
You might not know that P. chrysogenum has an older cousin who first arrived on the scene long before that. Around a thousand years ago, a shepherd abandoned his cheese sandwich in a cave, to take a second look at a young lady who was passing by. He returned later (cheese sandwiches being in short supply back then) to find his snack had become mouldy. Roquefort was born, thanks to the best efforts of P. roqueforti. I'll spare you the similarly authenticated tales of how Camembert and Gorgonzola came into being. It can be humbling to realise how much we owe to a family of moulds.

However, there is a dark sheep in this family.

The patient lies quietly in the HIV ward, which is aptly-named. He is staring at the ceiling in an isolated, six bed bay. We interrupt his thoughts. There are only three of us, which probably makes a welcome change for patients who are used to more than a dozen doctors and nurses on each ward round. He's known to have HIV, but he isn't receiving anti-retroviral drugs. For the last month he's been tired, coughing, losing weight, feverish. His chest X-ray is normal. He's very anaemic, and his liver and spleen are massively enlarged. He's had frequent nose-bleeds and he's obviously uncomfortable while we examine him. An unusual rash, reminiscent of chickenpox, covers him from head to toe.
The Consultant picks my brains: how can I explain all these findings? I'm quite proud to have come up with a half-dozen suggestions, even if they turn out to all be wrong. Which they do. I begin to plead ignorance. "Penicillium marneffei", I'm told. A fungus present only in South-East Asia which causes disease only in the immuno-compromised. I had strategically decided not to learn about it for finals, but it seems that the Penicillium family is greater than I had ever suspected.
A course of itraconazole and amphotericin B will cure him of his penicilliosis soon enough, but he'll still be left with the HIV. And before we curse the virus, it's worth noting that it has quickly become one of the most important tools in molecular biology today. These microbes just can't decide whether to be good or bad.

Information on P.marneffei

The Malaria Ward

No flip-flops, shorts or vests; white coats are compulsory. Those were the rules explained to me before my 1st ward round on the Malaria ward. A short walk in the shade of some palm trees takes us from the OUCRU (Oxford University Clinical Research Unit) to the ward. The last 25 metres are not sheltered from the sun, and it makes us pick up the pace. The shade of the malaria ward is most welcome, but the heat is still there. There's a small oasis of cool in the air-conditionned doctors' office, where we wait for everyone to assemble. To get there, we have to single-file past two beds which lie in the corridor, each one carrying a very tired-looking patient.
The ward's name is misleading: the vast majority of the patients on this ward (13 in total today) don't have malaria. The name is historical, as this was once the ward where all malaria cases were treated. There was a time when malaria was a great burden for Vietnam, as it still is in much of South-East Asia. In 1991, there were nearly 2 million cases and more than 4,500 deaths from malaria in this country. Since then, thanks to a massive commitment from the Vietnamese Government, and significant financial assistance from the World Bank, Vietnam has succeeded in almost eradicating the disease. By 2003, cases were down to 37,416 and there were only 50 deaths.
Based on this morning's round, a more suitable name would be the Meningitis ward. Bacterial, TB, viral; even eosinophilic, a new one for me. The Vietnamese doctors summarise the case in English, for the benefit of the 2 or 3 members of the round who don't speak Vietnamese. I listen carefully, trying to block out the noise of the large fans on the ceiling. Ceftriaxone, vancomycin, ampicillin - some rebel patients still refuse to get better. It's difficult when a CT scan implies a drive through the city in an ambulance; in a city like Saigon, the drive itself could prove more dangerous than the meningitis....
Having seen a single case of malaria, we leave the ward and enter the ICU. In a side-room, a young man lies spread-eagle on a bed, the haemofiltration machine doing its best to rid his blood of the parasites within it. "This patient spent many years in a malaria-endemic region of Vietnam", we are told. Those tend to be the more rural and forested parts of the country. "His parasitaemia level is nearly 10%". That's very high; I try to remember what the management for severe malaria is. "We think he has brain death".

And there it is, malaria's latest victim. Perhaps the name of the ward serves as a useful reminder.


Barat, LM. "Four malaria success stories: how malaria burden was successfully reduced in Brazil, Eritrea, India, and Vietnam." Am J Trop Med Hyg (2006); 74(1):12-6.

The end of infectious diseases?

In 1965, Dr William Stewart was appointed US Surgeon General. These were challenging times in Public Health. A year earlier, Stewart's wonderfully-named predecessor, Luther Leonidas Terry, had overseen the publication of a report on the links between smoking and lung cancer. This in turn followed a landmark report published in the UK in 1962, which stated clearly that smoking was a cause of lung cancer and bronchitis. These were the first steps in a long struggle between public health doctors and the tobacco industry, a fight which goes on today despite the advantage having clearly shifted from the latter to the former camp.
In 1967, William Stewart, realising that chronic diseases such as cancer, cardiovascular disease and diabetes would soon take over as the leading causes of mortality, infamously stated that it was "time to close the book on infectious disease" (well, maybe he didn't; some claim he was misquoted - perhaps he mis-spoke?). To be fair to him, antibiotics had recently revolutionised the treatment of communicable diseases, and immunisation programs were gathering pace in most developed countries. Polio was on the way out. Polio! There was obviously cause for optimism.
Well, the 1960s weren't just tough in the corridors of the Center for Disease Control and Prevention. The magnitude of the conflict in Vietnam was becoming plain for all to see - Stewart was actually under a lot of pressure to reduce public health expenditure because of the cost of the war. Yet Vietnam also offered good evidence that the book of infectious diseases was nowhere near its final chapter. In 1965, Cho Quan hospital in Saigon was building a new contagious diseases ward and a new operating room for leprosy patients. The hospital was already over 100 years old by then, and has kept on growing since - in 1979, it became the first hospital in Vietnam specialising in infectious diseases. Today it is called the Centre for Tropical Diseases, and it lies just outside the centre of Ho Chi Minh City.
A brief meeting this morning with Dr Chinh, Director of the hospital, reminds me that while infectious diseases seem quite small-print when you are in Oxford, they are very much the bread and butter of medicine in many parts of the world. At any one time there are at least 10 patients in the hospital suffering from tetanus. Then there's the TB, the dengue, the HIV. Oh, and malaria's thinking of making a comeback in Vietnam.
They're nowhere near extinction. Infectious diseases are here to stay and may well become an even greater problem as climate change exerts its effects. I expect the next few weeks will help drive the point home for me. If there are any interesting stories along the way (and I'm sure there will be), I'll let you know.