ABTSI + Leprosy Dan Flashcards
T/F
More Aboriginal and Torres Strait Islander people live in urban areas than remote communities
True
T/F
some people find use of the word ‘indigenous’ offensive
True
it is vital that you confirm what is the locally-preferred term with the people you work with and use it
What is an aborigine?
A person who is of Aboriginal descent, who identifies as an Aboriginal person, and is accepted as such by the community in which he or she lives
What is a Torres Strait Islander?
A person who is of Torres Strait Islander descent, who identifies as a Torres Strait Islander and is accepted as such by the community in which he or she lives
T/F
The following principles are important when interacting with indigenous pateints;
Introduce yourself and say where you are from
Use simple language
Avoid jargon
Take consultation slowly and gently
Be non-judgemental
Avoid direct questioning
Allow for silences
Allow for reflection and confirmation
ABTSI may go silent when an uncomfortable subject is being discussed. Try a different approach, consider help from a health worker, consider offering a doctor of the same sex as the patient if available
Utilise aboriginal health worker to facilitate consultation if needed
Clearly illustrate principles of disease and management
True
T/F
The prevalence of systemic lupus erythematosus is the same in Aboriginal Australians and in European Australians.
False
2-3x (2-3.8 in latest AJD paper) more in aborigines and also more severe
affects 1:1000 – 1:1900 Aborigines
T/F
Lupus erythematosus affects females more than males
True
DLE 5x more common in females regrdless of race
other LE also more common in females
T/F
It is unknown if the prevalence of LE in aborigines is genetically or environmentally determined
True
Theories include
Inherited deficiency of complement component C4A
Induction of cross reactive anti-dsDNA antibodies by bacterial infections and
Super antigen effect
Genetic variants that offer resistance to infectious diseases such as malaria.
T/F
Lupus erythematosus in aborigines has a high morbidity and mortality and high frequency of renal disease
True
T/F
Autoantibodies to the Sm antigen are uncommon in Lupus erythematosus in aborigines
False
common
T/F
The majority of deaths in aboriginal patients with SLE are due to renal failure
False
The majority of deaths in aboriginal patients with SLE are due to infection - associatd with active disease and with steroids
Which sites are most affected by cutaneous lupus?
nose, cheeks and forehead
but the lips, scalp and trunk may be involved
T/F
cutaneous lupus lesions are darker in darker skin
True
What is the carpet tack sign in cutaneous LE?
follicular plugs covered with scale – may be removed when scale scraped off or tape-stripped like lifting a carpet with the tacks pointing out from underneath
T/F
Erythema at the edge of the hyperpigmented lesions is characteristic of cutaneous lupus
True
hypopigmentation and scarring come later - often permanent
What are the acute, subacute and chronic stages of lower lip lupus?
acute - the lip is red, friable and bleeds easily
chronic - hypopigmentation and scarring
subacute stage is transition between these two
T/F
It is difficult for the clinician and histopathologist to distinguish verrucous lupus from Squamous cell carcinoma on the lip
True
T/F
The main differential diagnosis of LE in aborgines is tinea faciei
True
What are the common and rare organism causes of sepsis in aboriginal SLE pts?
gram negative and staphylococci - same as other pts
But also risk of rare pathogens eg. CNS cryptococcocis and disseminated strongyloidiasis
T/F
In mothers of infants with neonatal lupus almost all sera contain IgG antibodies to the SSA(Ro), 60KDa protein
True
Often also antibodies to 52KDa SSA(Ro) and to SSB(La)
small proprotion have antibodies to U1-RNP
Ro52 Abs carry highest association with congenital heart block, then Ro60
Pts with U1-RNP Abs alone usually don’t get CHB
T/F
skin biopsy is always necessary in an infant with a rash and features suspicious for neonatal LE
False
Take blood for serology and investigate mother
Only biopsy if diagnosis in doubt after other investigations
T/F
>90% of infants with NLE develop skin lesions
False
approx 50%
T/F
Rash of NLE usually resolves in 1st year without scarring but can cause residual hypopigmentation, epidermal atrophy or telangiectasia
True
atrophy is rare
T/F
Rash of NLE is photosensitive
True
T/F
NLE is the most common cause of Congenital Heart Block (CHB) where the structure of the heart is normal
True
T/F
20% of neonates born to mothers with anti-SSA antibodies will develop NLE
False
2%
2% also quoted as risk of having a baby with CHB
T/F
congenital heart block usually presents in utero commonly at 18 – 24 weeks of gestation
True
Incomplete heart blocks can progress after birth and once complete heart block is present it is irreversible
What are the other cardiac manifestation sof NLE other than heart block?
cardiac malformations
cardiomyopathy
prolonged QT interval
sinus bradycardia
T/F
thrombocytopenia in NLE usually doesnt cause clinical problems
True
can also get
Anaemia, neutropaenia and recurrent pancytopaenia
T/F
1 third of pts with CHB require PPM
False
2 thirds
What are the 3 presenations of liver disease in NLE?
fulminant liver failure presenting at or shortly after birth
cholestasis a few weeks after birth
transient mild-moderate transaminase elevations occurring a few weeks or months after birth
T/F
maternal breastfeeding is fine in cases of NLE
disocouraged as may transfer more lupus antibodies
T/F
Topical steroids do not reduce the frequency of hypopigmentation, telangiectasia and atrophy.
True
sun avoidance and sunscreen are mainstay
TCS usually not needed but can use HCT
What is risk to mother of having a second baby with NLE?
25% of recurrence in later pregnancy
T/F
Disseminated strongyloidiasis should be considered in ill immunosupressed patients in the Northern Territory
True
T/F
Squamous cell carcinoma of the lower lip is a complication of cutaneous lupus in Aboriginals
True
T/F
Sepsis as a cause of death is associated with oral corticosteroid use
True
T/F
The reason for the increased prevalence of lupus in Aboriginals is unknown
True
T/F In indigenous Australians there are high prevalences of metabolic syndrome components: • glucose intolerance • dyslipidaemia • hypertension • insulin resistance
True
The important factors leading to metabolic syndrome components are:
• social disadvantage
• limited economic opportunity
• adoption of diets of poor nutritional qualit
• rapid weight gain
True
T/F
Blindness is the most frequent complication of T2 diabetes in aboriginals
False
nephropathy
T/F
T2 diabetes in aboriginals has an incidence of end-stage renal failure that is 20–30 times that observed in Caucasian type 2 patients
True
T/F
Aboriginal patients with diabetes die at a significantly younger age than their Anglo-Celt counterparts
True
T/F Aboriginals in homelands participating in caring for country activities have: • less abdominal obesity • less diabetes • lower systolic BP • lower HBA1c levels and • lower cardiovascular disease risk
True
T/F
Indigienous women ahve a prevalence of PCOS of >25%
False
>15%
T/F
Acanthosis nigricans is common in overweight Aboriginal people
True
T/F
Acanthosis nigricans is most easily appreciated at the posterior neck in Aboriginal people
True
May also present in the axillae, inguinal area, abdominal fat folds and sometimes the flexures of the limbs
T/F
painful leg ulceration in a 45 year old Aboriginal is more likely to be vascular in origin than pyoderma gangrenosum
True
Always think of the complications of diabetes, renal disease and vascular disease
T/F
Before European colonisation of Australia, obesity was rare in Aboriginals
True
T/F
Indigenous Australians have a high prevalence of metabolic syndrome components
True
T/F
Vascular disease is rare in Aboriginal Australians
False
prevalence ranges from 10% – 70%
T/F
Group A streptococcus is a comon cause of skin sores (pyoderma) in Aboriginal children in Australia’s northern tropical regions
True
but often staph also present
What are the complications of Group A streptococcus pyoderma?
acute rheumatic fever
rheumatic heart disease
Post strep glomerulomephritis
T/F
Pyoderma and poor outocmes are more common in household overcrowding
True
T/F
The prevalence of pyoderma in children is higher during the wet season
False
higher during dry season
Increased outdoor activity and a greater chance of minor trauma and children tend to avoid swimming during these months as the water is colder
T/F
scabies predisposes to pyoderma
True
T/F
There is no link link between skin infections in childhood and the extreme rates of end-stage renal failure in Aboriginal adults
False
strong link
Acquiring APSGN in childhood increases the risk of adult renal disease by six times
T/F
Episodes of acute post streptococcal glomerulonephritis (APSGN) are five times higher for children with skin sores
True
T/F
Episodes of acute post streptococcal glomerulonephritis (APSGN) are five times higher for children with scabies
False
twice as common with scabies
5x with skin sores
T/F
Acquiring APSGN in childhood increases the risk of adult renal disease by 10 times
False
6x increase risk of adult disease after childhood APSGN
T/F
Indigenous Australians to die from kidney failure with a frequency 5x higher than non-Indigenous Australians
True
T/F
Indigenous Australians have end-stage renal disease 21x more than non-Aboriginal Australians and doubling every four years
True
T/F
Acute rheumatic fever is 60x more common amongst aboriginal children than non-aboriginal children
True
300 per 100,000 Vs 5 per 100,0000
T/F
pharyngeal carriage rates of group A β-haemolytic streptococci are high amongst aboriginal children
False
Low
strep complications due to skin infection not pahryngeal
Recurrent skin infection may confer a degree of immunity resulting in lower risk of strep throat
T/F
ARhF and RhHD are classic diseases of social injustice
True
T/F
Rates of ARhF and RhHD in aboriginals in the NT are declining
False
little or no evidence of improvement over at least the past three decades.
T/F
skin sores are more common on the trunk
False
usually the result of trauma and are more common on the limbs
T/F
Pus is unusual in skin sores
False
may look dry but pus under scabs
What triggers skin sores?
Trauma
insect bites and scabies
T/F
skin sores are transient and heal without scars
False
not always
can be chronic and leave scars
T/F
community acquired MRSA is common in some aboriginal communities
True
T/F
The use of ASOT and anti-DNA’ase B serology is not recommended for the diagnosis of impetigo
True
a high background and persisting levels of antibody in Aboriginal populations
T/F
The use of ASOT and anti-DNA’ase B serology is not recommended for the diagnosis of acute post streptococcal glomerulonephritis
False
should check in cases of gn as if high supports the diagnosis
T/F
topical antibiotics are first line for skin sores
False
topical antiseptic + oral treatment or IM benzathine penicillin 1st line
bactroban TDS for 7 days good choice if above cannot be used
Which oral antibiotics are used for skin sores?
what doses?
phenoxymethylpenicillin (penicillin VK) for 10 days is 98% effective
- 250-500mg QDS in adults
Cephalexin 500mg 3 times per day is usually effective if S.aureus is predominant
- treat kids with Wt-based dosing
Roxithromycin daily for 10 days is usually effective in penicillin allergic patients
- 300mg/day adults
- 5 to 8 mg/kg/day kid in divided doses
T/F
avergae monthly prevalence of pyoderma in East Arnhem is 35%
True
T/F
Skin sores are usually purely steptococcal
False
ofetn staph also
T/F
antibiotics must be given for 10 days for cases of beta haemolytic strep infection
True
T/F
Multiple skin sores are treated with benzathine penicillin
True
Single injection of 900mg for adults
single injection of 675mg (900,000 units) for older children
single injection of 225 to 450mg (30-600,000 units) for infants and children under 27kg
T/F
In remote indigenous communities scabies is endemic and prevalence rates are up to 50% in children and 75% in adults
False
50% in children and 25% in adults
T/F
Scabies is responsible for a significant percentage of streptococcal pyoderma in Northern Tropical Australia
True
What is a core infector of scabies?
Individuals in the comunity with individuals with hyperinfestation (crusted or Norwegian scabies) who infect other community members
T/F
Canine and human scabies mites are morphologically indistinguishable and dog mites can produce itch on human skin
True
T/F
Dog scabies can cause mange
True
Mange is a skin disease of mammals caused by parasitic mites and occasionally communicable to humans
when due to scabies is called scabetic mange
T/F
cycles of scabies transmission in dogs and humans appear to significantly overlap in Aboriginal communities
False
dont significantly overlap
T/F Scabies transmission (photo of eggs) usually occurs through direct skin contact with infected persons
True
T/F
Dog scabies cause itch in humans but not established infection
True
T/F
Scabies mites may survive for 56 hours off the human host
True
T/F
scabies live longer off the host in dry environment
False
survival enhanced by humidity
T/F
Inadequate “health hardware” (washing machines, toilets, taps, showers) and chronic overcrowding contribute significantly to scabies transmission in Aboriginal communities
True
T/F
truncal eczematous eruption is typical of scabies
True
T/F
scabies affects the genotals in men and the nipples in women
True
T/F
Scabies in babies tends to produce a papular vesicular eruption on the palms and soles
True
T/F
Secondary infection with streptococcus pyogenes and/or staphylococcus aureus makes scabies lesions easier to identify
False
obscures lesions and produces deeper ulceration
T/F
With age and multiple chronic infestations, the individual may develop tolerance to the scabies mite with few signs or symptoms
True
T/F
In elderly or with HTLV-1 or HIV there can be crusted scabies with no itch
True
should check for HTLV-1 or HIV in cases of crusted scabies
T/F
Usually there is a single strain of scabies in a community
False
multiple overlapping epidemic cycles indicating a wide circulation of diverse strains of sarcoptes scabiei
What is the India Ink Test for scabies?
blue felt tipped pen is applied to the suspected Burrow and the superficial ink is removed with an alcohol swab. The ink stays in the Burrow
Scraped off burrow with a blade and examine under microscope after an application of potassium hydroxide
T/F
Topical 5% permethrin cream is the treatment of choice for scabies
True
2 treatments 7-14 days apart
T/F
In tropical regions, especially for children, the neck, head and scalp should also be treated with permethrin for scabies
True
T/F
Permethrin can be used by women in the early stages of pregnancy and children from 2 months of age and probably younger
True
ACD module
Permethrin is B3
T/F
Benzyl benzoate can be used for scabies although irritation often leads to non-compliance
True
Ascabiol lotion = 25% benzyl benzoate (B2)
take hot bath and scrub skin
apply otion all over below neck
after 24 hrs take another hot bath
1 Rx often sufficient, can repeat after 5 days
sometimes 5% tea tree oil is added
T/F
Infantile acropustulosis may be a persistant post-scabetic reaction
True
T/F
Preciptated sulphur can be used for scabies
True
traditional choice for pregnancy and children up to 2 months
6-10% in Aq cream BD
Use for 3 days then leave final application on for 24 hrs
Not mentioned in college module
T/F
Household conatcts who are not clinically infecetd should be reated with permethrin
False
not necessary unless share a bed
Household contacts should be treated with cleaning of clothing, bedding and simple cleaning of the house
T/F
Ivermectin is metabolized by the liver and excreted in the faeces over an estimated 12 days
True
so nursing mother should not breast feed for 2 weeks after last dose
T/F
10% of ivermectin is excreted in urine
False
What is the dose of ivermectin?
200 micrograms per kilogram (3mg tabs)
- NB Wt-based number of tablet dosing in MIMs up to 80kg body weight
1 dose on day 1 and another dose between day 8 and day 15
3 doses if severe
7 dose regime and topical keratolytic for crusted scabies
T/F
Hepatic transaminases may become elevated during ivermectin therapy
True
T/F
ivermectin is excreted in the breast milk
True
T/F
Ivermectin should not be used in children under 25kg
False
not if under 5 years old or under 15kg
T/F
Septicaemia is a common complication of crusted scabies and is frequently polymicrobial
True
Rx aggressively treated with broad spectrum antibiotics
How should crusted scabies be managed?
Admit pt to single hospital room - isolation + contact precautions
Provide clean clothes daily and clean room thoroughly daily
FBC, Lymphocyte subsets, ELFTs, CRP, BSL
Urine MC&S, protein and RBCs, glucose and ketones
check HIV, HTLV-I, strongyloides and hepatitis B and C
ANA, ENA, DNA,C3 and C4, immunoglobulins, RhF, serum protein EPP, antiphospholipid antibodies and lupus anticoagulant
Treat sepsis and any other complications or untreated conditions
Topical scabicide
- permethrin every 2-3 days
- or benzyl benzoate 25%
Topical keratolytic is vital eg 6% sal acid in Aq cream +/- coal tar
Ivermectin 7 doses over 1 month;
- days 0, 1, 7, 8, 14, 21, 28
Can also use Condys baths and TCS for itch
Assess and treat household contacts while pt in hospital - GP and/or aboriginal health worker
T/F
comunity-based scabies control programs successful in achieving an initial reduction in scabies and pyoderma but the prevalence often rises back to a pre-interventional level within one year
True
Regular follow-up is required for a sustained reduction
T/F
Community initiated clean-up days play an integral part in promoting personal and household hygiene in scabies-affected communities
True
T/F
Crusted scabies results from failure of the host immune response to control the proliferation of the scabies mite in the skin, with resulting hyperinfestation and concomitant inflammatory and hyperkeratotic reaction
True
T/F
crusted scabies is very common in south australian aboriginal comunities
False
rare in south although scabies is common
crusted scabies most comon in central and north australia
What are risk factors for crusted scabies?
what additional risk factors are found in aboriginals?
HIV HTLV-1 T-cell lymphoma and leukaemia immunosuppression esp transplant pts SLE rheumatoid arthritis diabetes malnutrition neurological disorders - neuropathy, spinal injury, leprosy Dementia Downs’s syndrome arthropathy
additional risk factors are found in aboriginals;
past history of lepromatous leprosy
heavy Kava use
heavy alcohol use
T/F
IgE and eosinophil count are often raised in crusted scabies
True
T/F
ANA often positive in crusted scabies pts
True
T/F
C3 and C4 are often high in crusted scabies pts
False
low
What is mode of action of Ivermectin?
Semi synthetic macrocyclic lactone antibiotic. It disrupts the function of a class of ligand-gated chloride ion channels However the target of this drug in the scabies mite has yet to be identified and only a pH-gated chloride channel that is sensitive to ivermectin has been described
T/F
It is thought that in vertebrates P-glycoprotein drug pumps exclude ivermectin from its potential site of action resulting in no effect
True
T/F
P-glycoprotein substrates such as cyclosporine and HIV protease inhibitors may theoretically increase risk of human ivermectin neurotoxicity by competition for P-glycoprotein binding sites
True
But this has not been seen in studies or clinical practice
What is the most likely reason for scabies recurrence after treatment?
The most likely reason for recurrence is reinfestation
resistance to Ivermectin in scabies mites is another possibility
T/F
Ivermectin is neurotoxic in collies
True
T/F
Scabies in babies involves the head and neck in tropical areas
True
T/F
Canine scabies produces significant infestation in Aboriginal communities
False
T/F
Resistance to ivermectin is developing in scabies
False
still extremely rare
T/F
Staphylococcus aureus is the most common bacteria in infected scabies in Aboriginals
False
strep
T/F
Patients with crusted scabies should be tested for HTLV-1
True
and HIV
Which populations are at risk of community associated MRSA (CA-MRSA)?
sporting teams incarcerated persons the military children in day care facilities men who have sex with men indigenous communities across the world
T/F
Crowded living conditions, poor hygiene and poor access to medical care are risk factors for CA-MRSA
True
T/F
CA-MRSA is largely from a single strain in Australia
False
diverse strains in different parts of the country which have almost certainly arisen from the local indigenous population
T/F
Aboriginal populations have higher incience of both MSSA and MRSA infections
True
T/F
Staph infection incidence rates strongly correlate with measures of remoteness and socio-economic disadvantage
True
T/F
CA-MRSA was first noted in Australia amongst aboriginal populations and these communities may provide the reservoir from which the infections emerge into the wider community
True
T/F
CA-MRSA is a “feral descendent” of health care associated MRSA strains that had escaped into the community
False
new strains emerging locally
T/F
Western Samoan Phage Pattern (WSPP) strain of MRSA arrived in Australia from PNG
False
arrived in Australia via Auckland in New Zealand and has probably arisen in Samoa
Found in QLD and NSW
T/F
The Panton-Valentine leukocidin (PVL) gene is an important virulence factor associated with more severe skin and soft tissue infections including necrotising fasciitis, necrotising pneumonia, abscesses and death
True
T/F
NT-MRSA and the original WA-MRSA clones are PVL positive
False
PVL negative
But recently pvl has been detected in some WA-MRSA strains
Which MRSA strains in Aus are PVL positive?
USA 300
UK MRSA (rare in Aus)
Queensland MRSA
Western Samoan Phage Pattern (WSPP)
T/F
When practising in an area with indigenous patients, it is essential to know the pattern of antimicrobial resistance of the local S. aureus isolates
True
T/F
antibiotics are essential for MRSA abscesses
False
The primary treatment for a CA-MRSA abscess is surgical drainage
Many patients respond to drainage alone.
Which antibiotics can be used for MRSA infections?
Clindamycin 300mg TDS - 450mg QDS (C. diff risk)
Bactrim
Vancomycin 1st line for severe infections requiring hospital treatment
T/F
For recurrent furunculosis, tetracyclines, particularly vibramycin, can be taken for a longer period of time in association with an anti-staphylococcal regime if practical
True
T/F
MRSA can be transmitted between dogs and humans
True
In both directions
Poor dog health and dog overpopulation are major problems in many an Aboriginal community
How is staph eradication performed?
Chlorhexidine 4% bodywash/shampoo or Triclosan 1 - 2%
daily as wash for 5 days to body
wash hair on days 1,3,5
Nasal mupirocin ung
Use matchstick head-sized amount (less for small child)
Apply 3 times day for 5 days with cotton bud to inner surface of each nostril.
Massage gently upwards.
If applied correctly, patient can taste Mupirocin at back of throat
T/F
The Panton-Valentine leukocidin is associated with necrotising fasciitis
True
T/F
The WSPP strain predominates in NSW
True
T/F
Trimethoprim-sulfamethoxazole is effective treatment for indigenous patients with moderately severe skin infections
True
T/F
CA-MRSA infections can be diagnosed clinically
False
T/F
Tinea of the skin and nails affects 5-15% of aboriginal children
True
T/F
tinea capitis with Trichophyton tonsurans can be very mild manifesting as scaling and without hair loss in a few patches
True
T/F
Geophilic fungi are the main cause of tinea of the skin, nails and hair
False
Anthropophilic fungi are the main cause of tinea of the skin, nails and hair
T/F
Tinea corporis in aborigines is usually caused by Trichophyton rubrum or Trichophyton tonsurans
True
In NT and NSW aboriginal studies
T/F
Trichophyton tonsurans is almost always isolated from tinea capitis in aborigines
True