January 13, 2025 • 24 mins
Your hosts Dr George Moncrieff and Dr Roger Henderson are joined once again by special guest Dr Marina Morgan, Consultant Clinical Microbiologist at the Royal Devon and Exeter Hospital. Together, they explore the fascinating and sometimes alarming world of viral skin infections, covering conditions from glandular fever to tropical viral infections like dengue, chikungunya and Zika, along with the global spread of mpox.
Key takeaways:
- Recognising glandular fever and its differential diagnoses, including CMV and acute HIV seroconversion.
- How global travel and climate change are impacting the spread of tropical viral infections.
- The new dengue and mpox vaccines.
- Practical advice for identifying and managing mpox and its implications for patients and public health.
Tune in to gain valuable insights into the complexities of diagnosing and managing viral skin infections.
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The views expressed in this podcast are those of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated in or been involved in the programme, materials or delivery of this educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Hello and welcome once again tothis Rash Decisions podcast, where
we look at skin-related issues,conditions and treatments in an
interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice and I'm a former chair
(00:29):
of the Dermatology Council for England.
Remember, we talked about aspecial guest for this podcast.
Well, I'm delighted to introduce thefabulous Dr Marina Morgan, who you
may remember was also with us for ourpodcast on bacterial skin infections.
Marina is a Consultant ClinicalMicrobiologist at Royal
Devon and Exeter Hospital.
(00:51):
So welcome to the podcast, Marina.
It's really good to haveyou back with us today.
And we must have done somethingright for you to agree to come back.
Thank you.
It's a great privilegeand an honour to be here.
Thank you very much.
(01:11):
Thinking about viral infectionsaffecting the skin, if you've got a
maculopapular rash with enlarged glandsin a young person, particularly if
there's some malaise, we'd be thinkingabout glandular fever, wouldn't we?
EBV is probably thecommonest one, to be honest.
But, I'm afraid I've seen severalcases presenting very similarly
to glandular fever, that weren'tglandular fever and were missed.
(01:35):
Glandular fever, infectious mononucleosis,clinically, classically, is a triad
of fever, pharyngitis, and cervicallymphadenopathy, plus fatigue,
and often some palatal petechiaewhich people forget to look for.
But Cytomegalovirus producesvery similar symptoms, but
usually are quite a bit milder.
(01:56):
For adolescents or young adults, I'm sureyou're all used to asking for monospot
tests using an EDTA or full blood countsample, which is pretty sensitive.
And if the blood film's done andyou find atypical lymphocytes,
then that pretty well confirms EBV.
Unfortunately, like anydiagnostic test, false negatives
(02:16):
and false positives can occur.
And false negatives are common if youtest too early in the disease, before
the antibodies rise, or if you're testingchildren, particularly under four.
And false positives also can occurin HIV, cytomegalovirus, autoimmune
diseases, and haematological diseases.
So false negatives ifyou're too young, too early.
(02:39):
False positives if you've got a completelydifferent disease that can look the
same, like HIV or cytomegalovirus.
And so, essentially, if thediagnosis is in any doubt, you've
got to do proper EBV serology.
And that's basically sending a clottedsample of blood for us to actually
do proper antibody testing for theactual Epstein-Barr virus itself.
(03:00):
Beware, the biggest worry, of course, isthat those in their late teens onwards,
if they present with a rash and they'vegot a painless lymphadenopathy and an
atypical lymphocytosis, as well as theusual EBV, possible CMV, then acute
HIV seroconversion can be the cause.
We've seen a few of these inthe last 10 years as well.
(03:22):
Asking a detailed sexual history andenquiring about high-risk behaviour will
not only be helpful in diagnosis, butyou can just ask the lab to test for
HIV, EBV, and CMV on that one sample,as long as it's requested, we can do it.
Gosh, that is such an important message.
Thank you.
I think that's a practice-changingmessage, isn't it?
(03:44):
And really quite worrying,and of course makes sense.
It's a seroconversion rash.
Very interesting.
Thank you.
Actually, just as a complete aside there,if I do diagnose glandular fever, one of
the things I always do is very carefullyexamine the tummy for an enlarged spleen.
I've picked that up quite a few times.
It's only just slightly enlarged.
(04:04):
But if it's subtly enlarged,in glandular fever, the spleen
can be particularly friable.
So, very minor injuries, they falloff a bicycle, they come off a
ladder, or bang themselves againstthe bannister, can cause the spleen to
rupture with disastrous consequences.
I actually worked on a renal unitwhere, one of the patients, a
youngish woman, with end stage renalfailure, was due to exactly that.
(04:28):
She'd ruptured her spleenduring glandular fever.
So important advice just to avoidthose sorts of activities, such
an easy bit of advice to give andI would then monitor them until
that spleen is no longer palpable.
And of course, I'd also just think aboutchecking liver function at the same time.
So, glandular fever is more than justa sore throat and large glands and
(04:48):
malaise which can go on for a while.
There are things that we as a GP doneed to be thinking about and thinking
more holistically at the same time.
Absolutely right, George.
I remember as a medical student whenI had glandular fever, I was banned
from playing rugby for the best part ofsix months just for that, absolutely.
And I used to, I used to help out witha gastroenterology clinic as well,
(05:11):
and these were the things we alwaysused to double check for, and it's
such an important point to remember.
Now, Marina, if I can pop a question thatslightly concerns me, and this is the
return of the tropical traveller, whosecome back from their exotic pastures.
They've had a great time, and thenthey pitch up at my surgery and
(05:31):
they're just not very well, andthey've got a bit of an odd rash.
They think they might've bleda bit, but they might not,
and it's all a bit of a mess.
And you've got this list ofenormous differential tropical
diagnoses going through your head.
They can be a bit of anightmare, can't they?
Absolutely, and they're a bug doctor'snightmare as well, particularly if they've
(05:54):
only just come back from somewhere exotic.
But I think the firstthing is, don't panic.
Although all that we infection specialistsworry about is admitting a patient with
viral haemorrhagic fever and missing it.
So viral haemorrhagic fever is a virusthat haemorrhages and you've got a
fever, but it includes everything fromEbola and Lassa fever through to dengue,
(06:16):
which might kind of seem more familiar,but dengue can be pretty grim as well.
Essentially, if you catch dengue twice,you can develop dengue haemorrhagic
fever, which is really, really nasty.
And there's a whole load of moreexotic and even more unpronounceable
viral haemorrhagic fevers fromvery obscure parts of the globe.
And travellers are going all over theworld nowadays, and, I often can't even
(06:38):
spell half the places they've been to.
So, the bottom line is that if you'vegot somebody who pitches up, whose got
purpura, petechiae, bleeding gums, orjust if they look unwell and they've come
back from a foreign land that might bea high-risk area for viral haemorrhagic
fever, and that's, unfortunately, notjust Africa, the Far East or South America,
(06:59):
but some parts of Europe too.
Then you need to think of thepossibility of things as exotic
as viral haemorrhagic fever.
And if they've been in the right sort ofarea, and they're unwell, and particularly
if they've got pyrexia and bleeding, themost vital thing to ask is the timing.
So if they returned to the UKless than three weeks ago, then
that's still within the incubationperiod for all these nasty viruses.
(07:22):
And you've just got to think, couldthis be one of them, you know,
they don't look quite so bad at themoment, but is it the early stages?
Chances are, you know, things beingcommon, it's just malaria, and maybe
they've got a low platelet count due tomalaria, but you still have to have viral
haemorrhagic fever foremost in your mind.
So these patients need urgentdiscussion and referral.
(07:42):
It's always worth a phone call to yourlocal infection department and just check.
Because you can't know every partof the world that's got the latest
outbreak of something, and to becompletely geographically aware.
So, it's important to know wherethey've actually been, and when,
and when did they come back to theUK, and when they were there, were
they bitten by lots of mosquitoes?
(08:03):
Did they eat any bushmeat?
Have they been exposed to bats?
Tourists go spelunking and down intobat caves and things these days.
So there's all sorts of unusualoccupations and exciting adventures
that they can have abroad.
You've got to try and find out whatthey've been doing and you can go
into the deeper parts of that later.
But the first and most importantquestions are, have they been back
(08:23):
in the country for less than 21 days?
Are they really sick?
Is that end of the bed nick factor,that I was brought up to recognise
as a junior doctor, pretty poor?
Do they really look sick?
As George said earlier, ifin doubt, phone for help.
And if you're sending patientsinto hospital, please, warn the
(08:44):
ambulance service and the emergencydepartment so that they can prep.
Because they'll need to puton full protective equipment.
They'll need to isolate the patient.
And in our hospital, we've got apathway, we shut off the various doors.
And they have to come through acertain way [so] that they don't expose
themselves to lots of other patients.
So it's a bit of palaver.
But if you think you might have a viralhaemorrhagic fever, please warn people
(09:05):
that you're going to be sending them in.
Gosh, that's really, really interesting.
And just to turn that advice on its head.
If they've been in this country,and the symptoms are coming on,
more than three weeks after theyhave returned, we can relax.
Yep.
That's how I understand it.
I can't think of a virus that has morethan a three week incubation, that would
(09:25):
present, that's as dangerous as this.
Well, that's really, really useful.
Thank you.
But when I see a patient coming backfrom a tropical area, particularly
when I think of things like Tanzania,with a rash, one of the things
I'm thinking about is chikungunya.
And am I right in thinking that withglobal warming, some of these viruses,
the vectors are able to survivefurther north with global warming.
(09:47):
So not only dengue, but chikungunyais moving north as well.
Is that, so?
Yes, absolutely.
Chikungunya, there have been sporadiccases acquired locally from mosquitoes
in Northern Italy, Cyprus, the Easternshores of the Black Sea, and even Madeira.
Gosh, that is alarming, isn't it?
My goodness.
I always thought of it coming from,sort of, down in deep Africa, Tanzania,
(10:10):
is the place where I think of itmostly, along with O'nyong-nyong
disease, but, uh, gosh, okay.
Right up, up that far.
Goodness.
I think the problem is thatthese viruses are now as
geographically challenged as I am.
There's nowhere they won't go.
And I always have to look up on themap [for] any travellers coming in.
I have to look them up and find whereexactly they've been, because, you
(10:30):
know, it makes a big difference.
And then I then have to look it up on theCDC website or some other websites to see
what's currently an outbreak in that area.
Because it literally changesevery few weeks at the moment.
Um, and it's really quite difficultto keep up to speed with it.
On a different tack, I appreciateit's not a virus, but, topical
leishmaniasis or cutaneous leishmaniasis.
(10:52):
I've had a couple of cases who'veacquired that from a holiday
to Spain or even Portugal.
I think one was Spain, one was Portugal.
Yes, leishmaniasis can be broughtback to the UK by dogs coming
back, particularly from Spain.
Happily, we haven't had it transmittedfrom the dogs to the humans in the UK yet
because the insect vector isn't right.
But, you know, the potential is there.
I digress, I'm sorry.
You were telling us a bitmore about chikungunya.
(11:14):
Right, well, the name, 'chikungunya',I hope I'm pronouncing it properly,
is derived from an African wordmeaning, 'contorted', and chikungunya
is now being spread through differenttypes of mosquitoes that have
migrated along with global warming,and they're crossing the borders.
So both chikungunya and dengue presentwith a generalised erythematous rash.
(11:35):
A confirmation of diagnosis iseasy, once you've thought about it,
you just send some blood, that's aclotted blood specimen, to the local
lab, and ask for the right tests.
They'll usually insist on you knowingexactly where they've been, and when
they've come back, and a few moredetails, but it's an easy test to do.
So, dengue is classically more known asbreakbone fever, and that gives you a
(11:56):
maculopapular, and often a sunburn rash.
And you get really, reallybad pains in the bones.
You don't get the rash on the palmsand soles, though, with dengue.
And the rash can be ratherreminiscent of the sunburn rash
associated with toxic shock.
So a generalised erythema, really.
And it's the massive vasodilatationthat causes the rash.
(12:16):
And I know as a medical student, I've beenterribly impressed with the photographs.
You put the hand onto the abdomen orthe back and then lift your hand off.
You leave a wonderful pale imprint.
It's the sort of classical picturethat's in all infection textbooks.
You can also have a mucosalinvolvement and occasionally, very
occasionally, a vesicular eruption.
Essentially, dengue is moreof just a florid erythema.
(12:37):
It's uncomfortable,but you get through it.
The first time you have it, you usuallyget over it without many problems.
Unfortunately, the second time you meetit, you're immune to that one particular
strain of dengue for a short time,but there are four strains at least.
By the second time you meet it, thenyou will get a horrendous overreaction.
You get something called,'dengue haemorrhagic fever',
(12:58):
with a cytokine storm, and thismassive endothelial leakage.
So the capillaries leak, leadingto shock, and the patient has
to be put into intensive care.
And, it's just another infection that isno longer, as you say, George, [just] to
be expected in the tropics, but we'renow seeing [it] in some parts of Europe.
There have been some very sporadic casesacquired in Italy, Spain, and France,
(13:21):
but really, the most recent emergenceis in parts of the USA, like California,
Florida, Texas, and Los Angeles.
Those aren't the sort of places I wouldnormally associate with tropical diseases.
Not indeed, no.
So, they're moving so rapidly, theseagents, that I think as a GP it's
particularly hard, but you've gotto be on alert for any traveller and
(13:42):
people are travelling so much nowadays.
So, if they've been travellingto anywhere, they could
have something really nasty.
And then of course, you can't legislatefor cases like the patient that picked
up malaria and it wasn't diagnosed forquite a while in hospital, because they
haven't been to any malarious areas.
But it transpired that they'd got bittenby a mosquito whilst waiting in the
(14:02):
airport and the mosquito had escapedfrom another traveller's luggage.
So you're never gonna figure that out.
No, you're not.
That just feels unfair doesn't it?
It really does feel so unfair.
Wow, really, really interesting.
The haemorrhagic fever in denguethen, is that endothelial damage
or is that low platelet count?
So they can bleed into the skin, but theycan also bleed into other vital organs.
(14:26):
What's actually goingon pathophysiologically?
Just everything basically.
Um, the dengue haemorrhagic shock is sogrim that all you can do is to support it.
There's no neutralising agent that youcan use, unlike in streptococcal toxic
shock, where you can give immunoglobulin.
There's nothing else you can do really,though in the last couple of months,
a vaccine has been licensed in theUK, but it's only available privately.
(14:49):
And as you say, there are fourdifferent serotypes of dengue.
So, I suppose you can getit even more than twice.
If you get it a third time,is it even more dangerous?
I haven't read about anybody getting itmore than twice because they tend to cut
it out and they don't go travelling again.
So one can become immune to one serotypeand for two or three months you're
cross-protected against all four.
(15:11):
But thereafter you lose thatcross-immunity and you'll still
remain only immune to the serotypethat originally infected you.
And then if you get a second infectiondue to this complicated immune
interaction, it's all down to cytokinestorms again isn't it I think?
You just become very much sicker.
Gosh.
Nasty.
So I think we need to be more and morealert to that, don't we, as time goes by.
(15:33):
Very interesting.
Zika virus is still around, isn't it?
And we need to be keeping that atthe back of our minds, particularly
because of the worry about pregnancy.
But again, the rash isn'tparticularly specific, is it?
No, it's terribly unhelpful.
It hasn't read the textbooks.
Not everybody has the rash,and that doesn't help at all.
No.
Usually, Zika produces a mildly itchyrash with a touch of conjunctivitis
(15:57):
and some oedema of the hands andfeet, with arthralgia and fever.
And Zika's another one of those virusesthat gives you red palms and soles.
In pregnant women, though, the worryis, particularly those infected
during the first trimester, thatZika can produce microcephaly and
congenital ophthalmic abnormalities.
(16:17):
It's difficult to find accuratestatistics, but the risk is
of the order of 5%.
So, if you have a pregnant woman whoreturns having been unwell abroad,
particularly if she has a rash, in aZika area, it's worth doing serology,
and then refer them for obstetricalfollow up if they're positive.
And is the Zika area also movingfurther North with global warming?
(16:42):
Very good question, I don't knowthe answer to that, but I wouldn't
be the least bit surprised.
Right, okay.
But it's grim in pregnancy, and if you'renot pregnant, it's not a problem, is it?
It's not a problem toyou particularly, no.
You can't pass it on in this country,we haven't got the vector, have we?
No, we haven't got the vector to passit between people, but it can be passed
(17:04):
on by infected men in their semen.
Gosh, really?
Goodness, that's worrying, isn't it?
It is.
Happily, it's rare, but there areseveral cases reported in literature
and only one case of female-to-malespread during sex that I'm aware of.
Fascinating.
Right.
And I suppose of course things likeblood transfusion, that could pass
(17:27):
it on inadvertently, couldn't it?
Yep, all these viruses can betransmitted pretty well through
blood transfusions, I think.
And certainly, there havebeen several cases of Zika.
When I was a medical student, way backin the 70s, we were taught to tell
the difference between smallpox andchickenpox, and it was really important
at that time to learn about that.
I think that the last vaccine was givenin 1979, and the World Health Organisation
(17:52):
announced that the world was clearof this terrible scourge of smallpox.
It was wisely kept in some laboratories.
I think about sixlaboratories around the world.
But the thing that I heard that worries meis that, prior to about the 19th century,
if people died of smallpox in the Northerntundra's of Siberia or Northern Canada,
(18:12):
they weren't able to cremate the bodies.
Instead, they just buried themin the ice, and ice is a fairly
good way of preserving the virus.
But with global warming, thesebodies are being exposed.
Is there a worry that this virus is goingto be released into the environment,
into a vaccine [and] smallpox naivesociety, where anybody over the
(18:32):
age of 50 or so would be protected.
But all our fertile age group aregoing to be perfectly vulnerable to
this highly contagious, much morecontagious than chickenpox illness?
Is that a concern that weneed to be thinking about?
No, in that I think if there's a risk,the risk would be of a deliberate
release of smallpox, that's beensomeway genetically engineered.
(18:56):
The actual sort of permafrostedbodies, scientists have managed to
culture anaerobes from a permafrostedSiberian mammoth, for example.
But so far, the viruses that havebeen actually resuscitated, e.g.
the 1918 influenza virus, theone that caused the massive
pandemic in World War I.
The influenza virus from the permafrostbodies then, they managed to DNA
(19:19):
fingerprint, and not so far directlycultured it, but they used reverse
genetics technology to rebuild the virus.
So the virus can be rebuilt, but itwouldn't evolve naturally from this
permafrost to infect a human being.
The worry though is that monkeypox, whichis the most closely naturally related
to smallpox, could genetically evolveinto something much more contagious.
(19:42):
Good.
So I can put those concerns aboutsmallpox at the back of my mind.
I think so.
Hopefully.
Yeah.
Okay.
Now, monkeypox, as you say is muchmore closely related to smallpox, and I
think one of the distinguishing featuresis that unlike chickenpox where you
get crops of spots coming up over afew days and all of them maturing in
their own way, but at different stages.
(20:04):
In monkeypox, rather likesmallpox, the lesions are all
at the same stage of evolution.
So that, I believe, is one way inwhich we can tell the two apart,
so we can recognise monkeypox.
And it's normally associatedwith fairly intimate and sexual
contact, that's right, isn't it?
There are several differentclades, and some of them are more
household contacts and some aremore sexual contact, but certainly
(20:26):
close family contact can spread it.
The original monkeypox waslimited to a few cases of
humans in contact with monkeys.
Although, it's not exclusivelya monkey-carried pathogen.
There was a 2003 USA outbreakwhere just contact with prairie
dogs was the cause of catching it.
Right.
Gosh.
So, basically, it's closeskin-to-skin contact.
(20:46):
So, sexual contact orclose family contact.
The 2022 global outbreak, acouple of years ago, primarily
affected men who had sex with men.
Whereas before that, monkeypox was mainlyconfined to West and Central Africa
with our UK cases linked to travel orcontact with other travel-related cases.
So the virus is shed from lesions forabout three weeks until they heal,
(21:11):
and you get local lymphadenopathy.
And it's the localised lymphadenopathy,the site, and the synchronous evolution
of the lesions, as you say, theydon't come in waves, they're all
together, maturing, that help youdifferentiate monkeypox from varicella.
They're very, very painful lesions,and they're pretty much the
hallmark, and they all progressat the same rate, as I've said.
(21:32):
So you get a macule becoming a papule,evolving into a vesicle, and finally
ending up as a scab, and about 60%will have a sort of umbilication,
so they can look more like properpox, but apparently it's a very,
very unpleasant thing to have.
People have tried sitting in sitz baths.
(21:53):
When you're cleansing the lesions,if you're using the bath and using
a sitz bath, you've got to be reallycareful because those pox virus lesions
on your bottom will be absolutelyfull of virus and you've got to clean
the bath very thoroughly afterwards.
Otherwise, you could get fomite spread.
So an indirect spread betweenindividuals, is possible.
So, all sorts of treatments havebeen used, haemorrhoid treatments,
(22:15):
salt water rinses, and treatingany secondary bacteria infection
obviously would be necessary.
Happily, a new mpox therapy calledTecovirimat is very effective.
And there's a new vaccine whichneeds two shots for protection.
So basically, if you suspect mpox, youmust refer the patient to GU medicine.
Or at least discuss it withyour local infection service.
(22:37):
Oh, I'm really sorry.
I've just realised it's no longercalled monkeypox, now, I should
be referring [to] it only as Mpox.
And that's the new wordingthat we should be using.
And just as an aside, do you happento know whether hypochlorous,
aqueous hypochlorous solution,has any effect on this virus?
It'll obviously help secondaryinfection, things like Clinisept+.
(23:00):
I don't know, but I would imagineit probably would have some effect.
I've certainly not seenany papers on it...
So, it could be certainly [a]useful thing to use in the bath to
try and clear the bath afterwards,if someone's been in the bath?
Yes.
I'd certainly use a disinfectantto get all the scum off and then
I'd use an antiseptic of somesort and something like that.
Yeah.
Yes, I'd be probably quite neuroticdoing it, but then I am a bug doctor.
[Laughing] Indeed you are.
(23:21):
Marina, that was utterly,utterly fantastic.
Every time I chat withyou I just learn so much.
You are just such a mountain ofknowledge and it was just lovely talking
about these horrible diseases thatscare the living daylights out of me.
But you make them understandableand you give us hope and so many
useful, clear, helpful tips.
Thank you so much.
(23:42):
That's very kind of you.
Thank you.
Frankly, they scare the livingdaylights out of me, too.
Thank you.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
As always, George and I do hope you foundthis podcast as interesting, as helpful,
as we have, and that you've enjoyed theprevious [ones] on viral skin problems.
(24:04):
But if you haven't caught upwith those yet, do have a listen.
And if you like what you hear,then do rate and review us
wherever you get your podcasts.
It really does help us keepproducing quality content for you.
Or you can get in touch with questionsor suggestions for future podcasts,
as we really do love to hear from you.
But until then, it's goodbye fromour very special guest, Marina.
(24:27):
Goodbye.
It's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
Goodbye.
Hello and welcome once again tothis Rash Decisions podcast, where
we look at skin-related issues,conditions and treatments in an
interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice and I'm a former chair
(00:29):
of the Dermatology Council for England.
Remember, we talked about aspecial guest for this podcast.
Well, I'm delighted to introduce thefabulous Dr Marina Morgan, who you
may remember was also with us for ourpodcast on bacterial skin infections.
Marina is a Consultant ClinicalMicrobiologist at Royal
Devon and Exeter Hospital.
(00:51):
So welcome to the podcast, Marina.
It's really good to haveyou back with us today.
And we must have done somethingright for you to agree to come back.
Thank you.
It's a great privilegeand an honour to be here.
Thank you very much.
(01:11):
Thinking about viral infectionsaffecting the skin, if you've got a
maculopapular rash with enlarged glandsin a young person, particularly if
there's some malaise, we'd be thinkingabout glandular fever, wouldn't we?
EBV is probably thecommonest one, to be honest.
But, I'm afraid I've seen severalcases presenting very similarly
to glandular fever, that weren'tglandular fever and were missed.
(01:35):
Glandular fever, infectious mononucleosis,clinically, classically, is a triad
of fever, pharyngitis, and cervicallymphadenopathy, plus fatigue,
and often some palatal petechiaewhich people forget to look for.
But Cytomegalovirus producesvery similar symptoms, but
usually are quite a bit milder.
(01:56):
For adolescents or young adults, I'm sureyou're all used to asking for monospot
tests using an EDTA or full blood countsample, which is pretty sensitive.
And if the blood film's done andyou find atypical lymphocytes,
then that pretty well confirms EBV.
Unfortunately, like anydiagnostic test, false negatives
(02:16):
and false positives can occur.
And false negatives are common if youtest too early in the disease, before
the antibodies rise, or if you're testingchildren, particularly under four.
And false positives also can occurin HIV, cytomegalovirus, autoimmune
diseases, and haematological diseases.
So false negatives ifyou're too young, too early.
(02:39):
False positives if you've got a completelydifferent disease that can look the
same, like HIV or cytomegalovirus.
And so, essentially, if thediagnosis is in any doubt, you've
got to do proper EBV serology.
And that's basically sending a clottedsample of blood for us to actually
do proper antibody testing for theactual Epstein-Barr virus itself.
(03:00):
Beware, the biggest worry, of course, isthat those in their late teens onwards,
if they present with a rash and they'vegot a painless lymphadenopathy and an
atypical lymphocytosis, as well as theusual EBV, possible CMV, then acute
HIV seroconversion can be the cause.
We've seen a few of these inthe last 10 years as well.
(03:22):
Asking a detailed sexual history andenquiring about high-risk behaviour will
not only be helpful in diagnosis, butyou can just ask the lab to test for
HIV, EBV, and CMV on that one sample,as long as it's requested, we can do it.
Gosh, that is such an important message.
Thank you.
I think that's a practice-changingmessage, isn't it?
(03:44):
And really quite worrying,and of course makes sense.
It's a seroconversion rash.
Very interesting.
Thank you.
Actually, just as a complete aside there,if I do diagnose glandular fever, one of
the things I always do is very carefullyexamine the tummy for an enlarged spleen.
I've picked that up quite a few times.
It's only just slightly enlarged.
(04:04):
But if it's subtly enlarged,in glandular fever, the spleen
can be particularly friable.
So, very minor injuries, they falloff a bicycle, they come off a
ladder, or bang themselves againstthe bannister, can cause the spleen to
rupture with disastrous consequences.
I actually worked on a renal unitwhere, one of the patients, a
youngish woman, with end stage renalfailure, was due to exactly that.
(04:28):
She'd ruptured her spleenduring glandular fever.
So important advice just to avoidthose sorts of activities, such
an easy bit of advice to give andI would then monitor them until
that spleen is no longer palpable.
And of course, I'd also just think aboutchecking liver function at the same time.
So, glandular fever is more than justa sore throat and large glands and
(04:48):
malaise which can go on for a while.
There are things that we as a GP doneed to be thinking about and thinking
more holistically at the same time.
Absolutely right, George.
I remember as a medical student whenI had glandular fever, I was banned
from playing rugby for the best part ofsix months just for that, absolutely.
And I used to, I used to help out witha gastroenterology clinic as well,
(05:11):
and these were the things we alwaysused to double check for, and it's
such an important point to remember.
Now, Marina, if I can pop a question thatslightly concerns me, and this is the
return of the tropical traveller, whosecome back from their exotic pastures.
They've had a great time, and thenthey pitch up at my surgery and
(05:31):
they're just not very well, andthey've got a bit of an odd rash.
They think they might've bleda bit, but they might not,
and it's all a bit of a mess.
And you've got this list ofenormous differential tropical
diagnoses going through your head.
They can be a bit of anightmare, can't they?
Absolutely, and they're a bug doctor'snightmare as well, particularly if they've
(05:54):
only just come back from somewhere exotic.
But I think the firstthing is, don't panic.
Although all that we infection specialistsworry about is admitting a patient with
viral haemorrhagic fever and missing it.
So viral haemorrhagic fever is a virusthat haemorrhages and you've got a
fever, but it includes everything fromEbola and Lassa fever through to dengue,
(06:16):
which might kind of seem more familiar,but dengue can be pretty grim as well.
Essentially, if you catch dengue twice,you can develop dengue haemorrhagic
fever, which is really, really nasty.
And there's a whole load of moreexotic and even more unpronounceable
viral haemorrhagic fevers fromvery obscure parts of the globe.
And travellers are going all over theworld nowadays, and, I often can't even
(06:38):
spell half the places they've been to.
So, the bottom line is that if you'vegot somebody who pitches up, whose got
purpura, petechiae, bleeding gums, orjust if they look unwell and they've come
back from a foreign land that might bea high-risk area for viral haemorrhagic
fever, and that's, unfortunately, notjust Africa, the Far East or South America,
(06:59):
but some parts of Europe too.
Then you need to think of thepossibility of things as exotic
as viral haemorrhagic fever.
And if they've been in the right sort ofarea, and they're unwell, and particularly
if they've got pyrexia and bleeding, themost vital thing to ask is the timing.
So if they returned to the UKless than three weeks ago, then
that's still within the incubationperiod for all these nasty viruses.
(07:22):
And you've just got to think, couldthis be one of them, you know,
they don't look quite so bad at themoment, but is it the early stages?
Chances are, you know, things beingcommon, it's just malaria, and maybe
they've got a low platelet count due tomalaria, but you still have to have viral
haemorrhagic fever foremost in your mind.
So these patients need urgentdiscussion and referral.
(07:42):
It's always worth a phone call to yourlocal infection department and just check.
Because you can't know every partof the world that's got the latest
outbreak of something, and to becompletely geographically aware.
So, it's important to know wherethey've actually been, and when,
and when did they come back to theUK, and when they were there, were
they bitten by lots of mosquitoes?
(08:03):
Did they eat any bushmeat?
Have they been exposed to bats?
Tourists go spelunking and down intobat caves and things these days.
So there's all sorts of unusualoccupations and exciting adventures
that they can have abroad.
You've got to try and find out whatthey've been doing and you can go
into the deeper parts of that later.
But the first and most importantquestions are, have they been back
(08:23):
in the country for less than 21 days?
Are they really sick?
Is that end of the bed nick factor,that I was brought up to recognise
as a junior doctor, pretty poor?
Do they really look sick?
As George said earlier, ifin doubt, phone for help.
And if you're sending patientsinto hospital, please, warn the
(08:44):
ambulance service and the emergencydepartment so that they can prep.
Because they'll need to puton full protective equipment.
They'll need to isolate the patient.
And in our hospital, we've got apathway, we shut off the various doors.
And they have to come through acertain way [so] that they don't expose
themselves to lots of other patients.
So it's a bit of palaver.
But if you think you might have a viralhaemorrhagic fever, please warn people
(09:05):
that you're going to be sending them in.
Gosh, that's really, really interesting.
And just to turn that advice on its head.
If they've been in this country,and the symptoms are coming on,
more than three weeks after theyhave returned, we can relax.
Yep.
That's how I understand it.
I can't think of a virus that has morethan a three week incubation, that would
(09:25):
present, that's as dangerous as this.
Well, that's really, really useful.
Thank you.
But when I see a patient coming backfrom a tropical area, particularly
when I think of things like Tanzania,with a rash, one of the things
I'm thinking about is chikungunya.
And am I right in thinking that withglobal warming, some of these viruses,
the vectors are able to survivefurther north with global warming.
(09:47):
So not only dengue, but chikungunyais moving north as well.
Is that, so?
Yes, absolutely.
Chikungunya, there have been sporadiccases acquired locally from mosquitoes
in Northern Italy, Cyprus, the Easternshores of the Black Sea, and even Madeira.
Gosh, that is alarming, isn't it?
My goodness.
I always thought of it coming from,sort of, down in deep Africa, Tanzania,
(10:10):
is the place where I think of itmostly, along with O'nyong-nyong
disease, but, uh, gosh, okay.
Right up, up that far.
Goodness.
I think the problem is thatthese viruses are now as
geographically challenged as I am.
There's nowhere they won't go.
And I always have to look up on themap [for] any travellers coming in.
I have to look them up and find whereexactly they've been, because, you
(10:30):
know, it makes a big difference.
And then I then have to look it up on theCDC website or some other websites to see
what's currently an outbreak in that area.
Because it literally changesevery few weeks at the moment.
Um, and it's really quite difficultto keep up to speed with it.
On a different tack, I appreciateit's not a virus, but, topical
leishmaniasis or cutaneous leishmaniasis.
(10:52):
I've had a couple of cases who'veacquired that from a holiday
to Spain or even Portugal.
I think one was Spain, one was Portugal.
Yes, leishmaniasis can be broughtback to the UK by dogs coming
back, particularly from Spain.
Happily, we haven't had it transmittedfrom the dogs to the humans in the UK yet
because the insect vector isn't right.
But, you know, the potential is there.
I digress, I'm sorry.
You were telling us a bitmore about chikungunya.
(11:14):
Right, well, the name, 'chikungunya',I hope I'm pronouncing it properly,
is derived from an African wordmeaning, 'contorted', and chikungunya
is now being spread through differenttypes of mosquitoes that have
migrated along with global warming,and they're crossing the borders.
So both chikungunya and dengue presentwith a generalised erythematous rash.
(11:35):
A confirmation of diagnosis iseasy, once you've thought about it,
you just send some blood, that's aclotted blood specimen, to the local
lab, and ask for the right tests.
They'll usually insist on you knowingexactly where they've been, and when
they've come back, and a few moredetails, but it's an easy test to do.
So, dengue is classically more known asbreakbone fever, and that gives you a
(11:56):
maculopapular, and often a sunburn rash.
And you get really, reallybad pains in the bones.
You don't get the rash on the palmsand soles, though, with dengue.
And the rash can be ratherreminiscent of the sunburn rash
associated with toxic shock.
So a generalised erythema, really.
And it's the massive vasodilatationthat causes the rash.
(12:16):
And I know as a medical student, I've beenterribly impressed with the photographs.
You put the hand onto the abdomen orthe back and then lift your hand off.
You leave a wonderful pale imprint.
It's the sort of classical picturethat's in all infection textbooks.
You can also have a mucosalinvolvement and occasionally, very
occasionally, a vesicular eruption.
Essentially, dengue is moreof just a florid erythema.
(12:37):
It's uncomfortable,but you get through it.
The first time you have it, you usuallyget over it without many problems.
Unfortunately, the second time you meetit, you're immune to that one particular
strain of dengue for a short time,but there are four strains at least.
By the second time you meet it, thenyou will get a horrendous overreaction.
You get something called,'dengue haemorrhagic fever',
(12:58):
with a cytokine storm, and thismassive endothelial leakage.
So the capillaries leak, leadingto shock, and the patient has
to be put into intensive care.
And, it's just another infection that isno longer, as you say, George, [just] to
be expected in the tropics, but we'renow seeing [it] in some parts of Europe.
There have been some very sporadic casesacquired in Italy, Spain, and France,
(13:21):
but really, the most recent emergenceis in parts of the USA, like California,
Florida, Texas, and Los Angeles.
Those aren't the sort of places I wouldnormally associate with tropical diseases.
Not indeed, no.
So, they're moving so rapidly, theseagents, that I think as a GP it's
particularly hard, but you've gotto be on alert for any traveller and
(13:42):
people are travelling so much nowadays.
So, if they've been travellingto anywhere, they could
have something really nasty.
And then of course, you can't legislatefor cases like the patient that picked
up malaria and it wasn't diagnosed forquite a while in hospital, because they
haven't been to any malarious areas.
But it transpired that they'd got bittenby a mosquito whilst waiting in the
(14:02):
airport and the mosquito had escapedfrom another traveller's luggage.
So you're never gonna figure that out.
No, you're not.
That just feels unfair doesn't it?
It really does feel so unfair.
Wow, really, really interesting.
The haemorrhagic fever in denguethen, is that endothelial damage
or is that low platelet count?
So they can bleed into the skin, but theycan also bleed into other vital organs.
(14:26):
What's actually goingon pathophysiologically?
Just everything basically.
Um, the dengue haemorrhagic shock is sogrim that all you can do is to support it.
There's no neutralising agent that youcan use, unlike in streptococcal toxic
shock, where you can give immunoglobulin.
There's nothing else you can do really,though in the last couple of months,
a vaccine has been licensed in theUK, but it's only available privately.
(14:49):
And as you say, there are fourdifferent serotypes of dengue.
So, I suppose you can getit even more than twice.
If you get it a third time,is it even more dangerous?
I haven't read about anybody getting itmore than twice because they tend to cut
it out and they don't go travelling again.
So one can become immune to one serotypeand for two or three months you're
cross-protected against all four.
(15:11):
But thereafter you lose thatcross-immunity and you'll still
remain only immune to the serotypethat originally infected you.
And then if you get a second infectiondue to this complicated immune
interaction, it's all down to cytokinestorms again isn't it I think?
You just become very much sicker.
Gosh.
Nasty.
So I think we need to be more and morealert to that, don't we, as time goes by.
(15:33):
Very interesting.
Zika virus is still around, isn't it?
And we need to be keeping that atthe back of our minds, particularly
because of the worry about pregnancy.
But again, the rash isn'tparticularly specific, is it?
No, it's terribly unhelpful.
It hasn't read the textbooks.
Not everybody has the rash,and that doesn't help at all.
No.
Usually, Zika produces a mildly itchyrash with a touch of conjunctivitis
(15:57):
and some oedema of the hands andfeet, with arthralgia and fever.
And Zika's another one of those virusesthat gives you red palms and soles.
In pregnant women, though, the worryis, particularly those infected
during the first trimester, thatZika can produce microcephaly and
congenital ophthalmic abnormalities.
(16:17):
It's difficult to find accuratestatistics, but the risk is
of the order of 5%.
So, if you have a pregnant woman whoreturns having been unwell abroad,
particularly if she has a rash, in aZika area, it's worth doing serology,
and then refer them for obstetricalfollow up if they're positive.
And is the Zika area also movingfurther North with global warming?
(16:42):
Very good question, I don't knowthe answer to that, but I wouldn't
be the least bit surprised.
Right, okay.
But it's grim in pregnancy, and if you'renot pregnant, it's not a problem, is it?
It's not a problem toyou particularly, no.
You can't pass it on in this country,we haven't got the vector, have we?
No, we haven't got the vector to passit between people, but it can be passed
(17:04):
on by infected men in their semen.
Gosh, really?
Goodness, that's worrying, isn't it?
It is.
Happily, it's rare, but there areseveral cases reported in literature
and only one case of female-to-malespread during sex that I'm aware of.
Fascinating.
Right.
And I suppose of course things likeblood transfusion, that could pass
(17:27):
it on inadvertently, couldn't it?
Yep, all these viruses can betransmitted pretty well through
blood transfusions, I think.
And certainly, there havebeen several cases of Zika.
When I was a medical student, way backin the 70s, we were taught to tell
the difference between smallpox andchickenpox, and it was really important
at that time to learn about that.
I think that the last vaccine was givenin 1979, and the World Health Organisation
(17:52):
announced that the world was clearof this terrible scourge of smallpox.
It was wisely kept in some laboratories.
I think about sixlaboratories around the world.
But the thing that I heard that worries meis that, prior to about the 19th century,
if people died of smallpox in the Northerntundra's of Siberia or Northern Canada,
(18:12):
they weren't able to cremate the bodies.
Instead, they just buried themin the ice, and ice is a fairly
good way of preserving the virus.
But with global warming, thesebodies are being exposed.
Is there a worry that this virus is goingto be released into the environment,
into a vaccine [and] smallpox naivesociety, where anybody over the
(18:32):
age of 50 or so would be protected.
But all our fertile age group aregoing to be perfectly vulnerable to
this highly contagious, much morecontagious than chickenpox illness?
Is that a concern that weneed to be thinking about?
No, in that I think if there's a risk,the risk would be of a deliberate
release of smallpox, that's beensomeway genetically engineered.
(18:56):
The actual sort of permafrostedbodies, scientists have managed to
culture anaerobes from a permafrostedSiberian mammoth, for example.
But so far, the viruses that havebeen actually resuscitated, e.g.
the 1918 influenza virus, theone that caused the massive
pandemic in World War I.
The influenza virus from the permafrostbodies then, they managed to DNA
(19:19):
fingerprint, and not so far directlycultured it, but they used reverse
genetics technology to rebuild the virus.
So the virus can be rebuilt, but itwouldn't evolve naturally from this
permafrost to infect a human being.
The worry though is that monkeypox, whichis the most closely naturally related
to smallpox, could genetically evolveinto something much more contagious.
(19:42):
Good.
So I can put those concerns aboutsmallpox at the back of my mind.
I think so.
Hopefully.
Yeah.
Okay.
Now, monkeypox, as you say is muchmore closely related to smallpox, and I
think one of the distinguishing featuresis that unlike chickenpox where you
get crops of spots coming up over afew days and all of them maturing in
their own way, but at different stages.
(20:04):
In monkeypox, rather likesmallpox, the lesions are all
at the same stage of evolution.
So that, I believe, is one way inwhich we can tell the two apart,
so we can recognise monkeypox.
And it's normally associatedwith fairly intimate and sexual
contact, that's right, isn't it?
There are several differentclades, and some of them are more
household contacts and some aremore sexual contact, but certainly
(20:26):
close family contact can spread it.
The original monkeypox waslimited to a few cases of
humans in contact with monkeys.
Although, it's not exclusivelya monkey-carried pathogen.
There was a 2003 USA outbreakwhere just contact with prairie
dogs was the cause of catching it.
Right.
Gosh.
So, basically, it's closeskin-to-skin contact.
(20:46):
So, sexual contact orclose family contact.
The 2022 global outbreak, acouple of years ago, primarily
affected men who had sex with men.
Whereas before that, monkeypox was mainlyconfined to West and Central Africa
with our UK cases linked to travel orcontact with other travel-related cases.
So the virus is shed from lesions forabout three weeks until they heal,
(21:11):
and you get local lymphadenopathy.
And it's the localised lymphadenopathy,the site, and the synchronous evolution
of the lesions, as you say, theydon't come in waves, they're all
together, maturing, that help youdifferentiate monkeypox from varicella.
They're very, very painful lesions,and they're pretty much the
hallmark, and they all progressat the same rate, as I've said.
(21:32):
So you get a macule becoming a papule,evolving into a vesicle, and finally
ending up as a scab, and about 60%will have a sort of umbilication,
so they can look more like properpox, but apparently it's a very,
very unpleasant thing to have.
People have tried sitting in sitz baths.
(21:53):
When you're cleansing the lesions,if you're using the bath and using
a sitz bath, you've got to be reallycareful because those pox virus lesions
on your bottom will be absolutelyfull of virus and you've got to clean
the bath very thoroughly afterwards.
Otherwise, you could get fomite spread.
So an indirect spread betweenindividuals, is possible.
So, all sorts of treatments havebeen used, haemorrhoid treatments,
(22:15):
salt water rinses, and treatingany secondary bacteria infection
obviously would be necessary.
Happily, a new mpox therapy calledTecovirimat is very effective.
And there's a new vaccine whichneeds two shots for protection.
So basically, if you suspect mpox, youmust refer the patient to GU medicine.
Or at least discuss it withyour local infection service.
(22:37):
Oh, I'm really sorry.
I've just realised it's no longercalled monkeypox, now, I should
be referring [to] it only as Mpox.
And that's the new wordingthat we should be using.
And just as an aside, do you happento know whether hypochlorous,
aqueous hypochlorous solution,has any effect on this virus?
It'll obviously help secondaryinfection, things like Clinisept+.
(23:00):
I don't know, but I would imagineit probably would have some effect.
I've certainly not seenany papers on it...
So, it could be certainly [a]useful thing to use in the bath to
try and clear the bath afterwards,if someone's been in the bath?
Yes.
I'd certainly use a disinfectantto get all the scum off and then
I'd use an antiseptic of somesort and something like that.
Yeah.
Yes, I'd be probably quite neuroticdoing it, but then I am a bug doctor.
[Laughing] Indeed you are.
(23:21):
Marina, that was utterly,utterly fantastic.
Every time I chat withyou I just learn so much.
You are just such a mountain ofknowledge and it was just lovely talking
about these horrible diseases thatscare the living daylights out of me.
But you make them understandableand you give us hope and so many
useful, clear, helpful tips.
Thank you so much.
(23:42):
That's very kind of you.
Thank you.
Frankly, they scare the livingdaylights out of me, too.
Thank you.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
As always, George and I do hope you foundthis podcast as interesting, as helpful,
as we have, and that you've enjoyed theprevious [ones] on viral skin problems.
(24:04):
But if you haven't caught upwith those yet, do have a listen.
And if you like what you hear,then do rate and review us
wherever you get your podcasts.
It really does help us keepproducing quality content for you.
Or you can get in touch with questionsor suggestions for future podcasts,
as we really do love to hear from you.
But until then, it's goodbye fromour very special guest, Marina.
(24:27):
Goodbye.
It's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
Goodbye.
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