Virtual Doctors work

This month’s case comes from the Chikupi clinic, a clinic we haven’t visited in the blog before. Chikupi is found in Kafue district, north west of Kafue town where the local hospital resides. It is a small rural area which has a school.

In the west of Kafue district lies a little known national park called the blue lagoon national park. It was closed to the public until recently so remains truly unspoilt. The plains are vast, a Serengeti-style grassland during the dry season with a complete transformation to watery wonderland in the wet. Migratory birds arrive from far and wide making it a bird watchers paradise. The plains are fringed by acacia trees and filled with an abundance of wildlife including Kafue lechwe (water loving antelope), zebra, sitatunga (marshbuck) and some buffalo. Occasionally huge water python are attracted to the area due to the rich pickings!

Virtual Doctors support 7 rural health centre and Kafue district Hospital in the centre of Kafue.

A 9 year old was bought by her family to Chikupi health centre with a four day history of rash on her face. She had vesicles (small blisters) on and around her eyelid and was clearly in pain. The eye itself was quite red. She was HIV negative. The clinical officer had started her on some antibiotic eye drops and some oral antiviral medicine. He sent a query to the virtual doctors along with a fantastically clear photograph. The virtual doctor confirmed this was ophthalmic shingles (shingles involving the eye).

The main concern is the eye and in the UK this patient would be seen by an eye specialist to examine the cornea, the clear layer in front of the eye, carefully and possibly put the patient on steroid eye drops. However this was not an option open to the Zambian clinical officer. He was advised to patch the eye to protect it, bath the eye and use antiviral eye drops if available.

What is Shingles?

Shingles is an infection of a nerve and the skin around it that causes a painful, blistering rash. The infection is caused by the varicella-zoster virus which also causes chicken pox. Approximately 1 in 4 people will have an episode of shingles during their lifetime.

Most people have chicken pox in childhood and following the infection the varicella-virus remains inactive (dormant) in the nervous system, in the nerve cells near your spine. Usually the immune system keeps the virus under control but it can be reactivated later and cause shingles. It is not known exactly why the varicella-zoster virus gets reactivated but most cases are thought to be caused by having lowered protection against infections and diseases. So this might be due to age, as you get older your immunity may decrease; having HIV and AIDS which weakens the immune system; physical and emotional stress and medication such as chemotherapy which can temporarily weaken your immune system.

Any part of the body can be affected but due to it following the area supplied by the nerve root affected, it affects one specific area on just one side of the body. An episode of shingles typically lasts between 2-4 weeks. In about 10-20% of people the rash appear in and around the eye. This is called ophthalmic herpes zoster. This is what we see in this month’s patient. Shingles in the eye can cause complications such as scarring and vision loss. So we will focus on this type of shingles.

Ophthalmic Shingles

The blistering rash forms as can be seen in the photo, on the eyelids, forehead and sometimes the side of the nose. This is due to the virus being reactivated in part of the trigeminal nerve, a nerve that controls sensation and movement in the face.

Along with the rash there might be burning or throbbing pain in the eye, redness around and in the eye (conjunctivitis), watering of the eye, blurred vision and extreme sensitivity to light.

Swelling can also occur in the eyelid, the retina (the light-sensitive layer at the back of your eye) and the cornea (the clear layer in front of your eye) causing complications.

Complications

Although the rash will fade after a few weeks the pain can continue for many more weeks and sometimes months. This is called post-herpetic neuralgia and is caused by damage to the nerve.

In the eye swelling of the cornea may be severe enough to cause permanent scarring. It can also increase the internal pressure in the eye and lead to a condition called glaucoma. Glaucoma damages the optic nerve (the nerve that transmits visual information to the brain).

Treating shingles in the eye quickly can help avoid these long term problems including permanent vision loss.

Treatment

The mainstay of treatment is early use of antiviral medication such as acyclovir, fanciclovir. They help to stop the virus spreading, heal the blisters and relieve pain. Starting them within 3 days of the rash developing can help avoid long term complications.

To reduce eye swelling steroid eyedrops or oral steroids can be prescribed. For the pain analgesics can be taken and sometimes tricyclic antidepressants – these can be particularly helpful to relieve the nerve pain.

In the early stages of ophthalmic shingles the eye really needs checking every few days and then 3-monthly for the next year to check for glaucoma and scarring.

Disclaimer: This article is for information only and shouldn’t be used for diagnosis or treatment of medical conditions. If you have any concerns about your health consult a doctor or other health professional

Cholera Outbreak

We are watching the situation in Lusaka closely as there have been a number of reported cases of cholera in the last month. Cholera broke out on 6th October 2017. According to the Lusakatimes, Dr Chilufya, the health minister, told Journalists in Lusaka that the affected compounds are Mazyopa, Kabanana, Chipata and SOS village where the majority of the residents are in informal settlements and depend on boreholes to access water for domestic use, including drinking. Dr Chilufya says of the total number of 48 people who have been affected by cholera, only eight remain in hospital. He say six people have been admitted to Kanyama while two others to Chipata clinic according to ZNBC news..

Cholera outbreaks have been a common occurrence in recent years in Zambia. According to a World Health Organization (WHO) Global Task Force on Cholera Control country profile for Zambia published in February 2011, an analysis of available rainfall and epidemic data in Lusaka shows a very strong association between rainfall and epidemic outbreaks in the city.
Outbreaks usually start during the month of October and end between mid-May/beginning of June of the following year corresponding to the rainy season.