Postgrad Med J: first published as 10.1136/pgmj.41.480.584 on 1 October 1965. Downloaded from POSTGRAD. MED. J., (1965), 41, 584 INFECTIONS OF IMMIGRANTS

J. H. WALTERS, M.D., F.R.C.P. Hospital for Tropical Diseases, London, N.W.1.

DISEASES carried by immigrants to this country has a low degree of infectivity especially in from the Tropics include infections-viral, adult life, when only about 5% of the popula- bacterial, protozoal and helminthic. tion retain any degree of susceptibility. The Of these infections, some are transmissible last known example of transmission of Hansen's and constitute a public health menace, some disease in the British Isles occurred some 100 have only a very low degree of infectivity and years ago in Ireland, when a soldier invalided give rise to little anxiety and some are inno- from the Far East returned to his family cuous under conditions which obtain in the cottage where he shared a bed with his young United Kingdom. Smallpox is an example of brother, who later fell a victim to the disease the first group, leprosy of the second and (Jopling, 1965). This ancedote illustrates two ancylostomiasis of the third. While many such important epidemiological aspects of leprosy, infections are ubiquitous in the Tropics, others namely the relatively high susceptibility of

have a strictly regional endemicity, some know- children and the necessity for prolonged inti-Protected by copyright. ledge of which is essential to practitioners in mate contact with an infective patient for this country. This point has been emphasised transmission to take place. Exceptions do by Maegraith (1963) in a striking article en- occur, however, and one meets occasional titled "Unde Venis?" (Whence have you European patients who have acquired the dis- come?). ease in adult life in the East through casual and usually unknown contact. I recall the Tuberculosis case of a Roman Catholic missionary priest Foremost among immigrant infections is from India, a British soldier, who served in tuberculosis which is understandable since it that country during World War II and an has now attained the status of the leading English water-works engineer from Northern tropical disease. The disease may present itself Nigeria. The incutbation period may be long, in unusual guises, especially among children, in for infection acquired in childhood may re- whom fever and wasting may be associated main latent or inactive until adult life, when

with polyadenitis and enlargement of the liver unusual stress or intercurrent infection mayhttp://pmj.bmj.com/ and the spleen, though the chest X-ray reveals allow it to manifest itself. The disease displays no obvious infiltration and the hilar glands do many different facets, reflecting the varying not appear significantly enlarged. Such a con- degree of inherent resistance of the persons dition seems to result from a bacterial invasion affected. Well-resisted disease presents as one of the systemic circulation of low intensity. or more large, asymmetrical areas, having a Acute caseous bronchopneumonia may develop pink, raised, well-defined granulomatous in adults and Negro immigrants are especially margin, within which is a flattened, atrophic prone to such ill-resisted types of the disease. area of skin which is devoid of hair, hypo- on September 25, 2021 by guest. Tuberculous salpingitis and endometritis are nigmented, unable to sweat and showing not uncommon in immigrants from any tropical impaired appreciation of all forms of sensation. countrv, while tuberculous ileitis will be en- This is the typical tuberculoid lesion, but an countered more frequently than Crohn's dis- unusual variant is the flat, atrophic hypo- ease. pigmented macule. Both these lesions may be accompanied by thickening of the regional Leprosy sensory nerves, while damage to the motor Leprosy, though widespread in the tropical fibres of affected mixed nerves often leads to belt, still occurs quite commonly in the Mediter- weakness and muscle wasting. Occasionally a ranean basin; Cyprus and Malta being the single peripheral nerve such ;as the ulnar or source from which a number of infected im- the facial may be damaged, though no skin migrants have reached this country. The disease lesion can be found. Nerve biopsy is then Postgrad Med J: first published as 10.1136/pgmj.41.480.584 on 1 October 1965. Downloaded from October, 1965 WALTERS: Infections of Immigrants 585 essential to establish the diagnosis. Next to lopment of a few widely scattered pinkish these lesions, which represent efficient resistance papules, by a slight coarsening of the features in the skin, are the dimorphous lesions, in with thinning of the eyebrows, or by occur- which the balance of invasiveness of the organ- rence on the trunk of subtle ill-defined macules ism and resistance of the host is precarious. described above. Nevertheless in such patients This is an unstable phase, and in the absence Hansen's bacilli may be found in skin scrapings of treatment, generalised invasion of the skin, taken from any part of the body and from mucous membranes and reticulo-endothelial the nasal septum. Lepromatous leprosy may system-the lepromatous form of the disease- involve the eye, in which miliary lepromata may supervene. Dimorphous leprosy is may develop in the cornea, the iris, in which characterised by large, asymmetrical macules they look like minute seed pearls, and on the usually visible as rings having clearcut inner retina. Invasion of the testis may lead to margins enclosing an atrophic, hypoaesthetic atrophy, to -which gynaecomastia may be a zone, while the induration and hyperaemia sequel. A progressive osteitis of the phalangeal gradually fade at the periphery to merge into bones, together with repeated painless trauma, normal skin. A symmetrical polyneuritis with often leads to a gradual absorption of these palpable thickening of nerves is commonly bones, with shortening and distortion of the associated with this type of lesion. In contrast digits. Trophic ulcers provide a grave problem with the tuberculoid types of lesion, in which and often lead to osteomyelitis and to the lepra bacilli are exceedingly scanty, the'casual total disorganisation of joints, epecially in the organisms can be found in moderate numbers foot. in both the dermis and the damaged nerves. Leprosy in this country may present a difficult

Lepromatous leprosy develops when an ade- diagnostic challenge and patients not rarely Protected by copyright. quate cytological defence fails to mobilise at remain for long periods under incorrect treat- the point of entry in the skin. In the absence ment. Although therapy is comparatively of an encompassing granulomatous reaction, straightforward in the case of the well-resisted histiocytes are invaded and provide both an tuberculoid and maculo-neural types of the efficient nidus for the corynebacteria and also disease, and can be conducted on an out- a transport system which disseminates them patient basis, the management of the disease through the entire reticulo-endothelial system. in its dimorphous and lepromatous forms re- The characteristic facies is striking for the skin quires much experience, and protracted hospital of the face is much thickened and nodules may treatment is always necessary. Two special develop at any site, especially on the pinnae; institutions exist in England for this purpose, the normal furrows are accentuated and eye- the Jordan Hospital, which is a branch of the brows and eyelashes are shed. The nose is Hospital for Tropical Diseases, London and the obstructed and ulceration of the septum may Home of St. Giles in Essex. The advice of a cause it to collapse. The larynx may be affected, consultant in leprosy may be obtained in any http://pmj.bmj.com/ causing hoarseness or loss of voice and laryn- area by application to the local Medical Officer geal stenosis may develop. The skin of the of Health. trunk may be generally infiltrated, but it is more common for ill-defined, slightly indurated Venereal Diseases plaques with a greasy surface to appear; these Venereal diseases probably rank next in show no loss of sensation and sweating is importance among immigrant infections. retained. These look plaques slightly pale on a Syphilis and gonorrhoea need no special men- on September 25, 2021 by guest. coloured skin, and slightly ervthematous on tion except to note that among coloured races the European skin. The extremities very often the commonest manifestations of neurosyphilis show puffiness or oedema and the skin is cold, are meningovacular in type, usually developing hyperaemic and cyanosed, suggesting a disturb- as a transverse myelitis of the thoracolumbar ance of neuro-vascular control. A thickened, segments, or as a basal meningitis involving hairless, highly polished appearance of the skin cranial nerves, especially the sixth and seventh. over the shins may be quite striking. A degree Lymphogranuloma inguinale, due to a large of symmetrical polvneuritis with thickening of virus of the psittacosis group, is common among the affected nerves is usually found but is most immigrants from the Caribbean area. The marked in those who have passed through a usual form of presentation is as a suppurating prolonged dimorphous phase. Many variants inguinal lymphadenitis, involving also the deep of this classical picture may occur, and some- iliac group of glands, with marked peri-adenitis. times the disease is revealed only by the deve- There is considerable constitutional disturbance 586 POSTGRADUATE MEDICAL JOURNAL October, 1965Postgrad Med J: first published as 10.1136/pgmj.41.480.584 on 1 October 1965. Downloaded from and much pain and local tenderness. Sinuses symptomatic amoebiasis is rare. In asympto- form and discharge a glairy, grey, mucoid matic or mild amoebiasis the infection can pus. Yet the disease may present a variety of usually be eradicated by a 10 day's course of other facets, which may lead to errors in diag- entamide furoate (Furamide, Boot's), 500 mg. nosis. An initial implantation of the virus with- being given three times daily by mouth. This in the urethral meatus may cause an acute drug has no toxic side effects. uretehritis, from which the virus may be Carriers of Shigella or Salmonella organisms transported to the pelvic glands, whence it may are equally unusual, but if found, require invade the rectum causing a chronic granulo- treatment with an antibiotic appropriate to matous proctitis. Direct infection of the rectum their sensitivity. by homosexual practice may occur. In the female, spread of the lesion from the vulva Infection with the protozoon, Giardia lamb- gives rise to the destructive genito-ano-rectal lia, is extremely common throughout the syndrome. The colonic lesion in either sex may tropics, and since this parasite is a potent extend from the anal canal to the splenic source of duodenal and jejunal irritation and is flexure, and there may be "skip" lesions. A even capable of causing a gross malabsorption granulomatous and stenosing submucous in- syndrome, its eradication is essential. This is flammation undermines the mucous membrane easily achieved by the use of mepacrine 100 which is ultimately shed. In either sex mg. t.d.s. for seven days, though treatment may extensive invasion of the inguinal lymphatic occasionally have to be repeated after one glands may be followed by a sclerosis which month's interval, to obtain complete eradica- obstructs permanently the lymphatic drainage tion. and genitalia-this may lead Helminthic infections abound among im- of the lower limlb Protected by copyright. to gross elephantiasis of the vulva, a condition migrants from the Tropics and commonly called estiomene. The diagnosis is confirmed comprise ascardiasis, , ancylostomia- by the Frei skin test or by using a chick yolk- sis and . Only the first two can sac culture of the virus in a complement fixa- be transmitted by direct faecal contamination of tion reaction. Sulphonamides, tetracycline and food; the third and fourth parasites undergo chlortetracycline are curative, but stenosis of stages of development in the soil and infect the bowel may require surgical measures. fresh hosts by the direct penetration of their A further venereal disease not uncommon larvae through the skin of the feet. among immigrants from the Caribbean islands can conveniently be treated with piperazine is granuloma venereum or ulcerating granuloma compounds, the usual preparation being pipera- of the pudenda; this is caused by a small intra- zine adipate (Antepar, Burroughs Wellcome and cellular organism called Klebsiella granulomatis Co.), 1800 mg. as a single dose given after an and referred to as the Donovan body when overnight fast, without subsequent purgation. An is it is seen within histiocytes in stained biopsy alternative preparation Pripsen. (Westminsterhttp://pmj.bmj.com/ sections. The characteristic lesion is a very Lalboratories) in a single dose of 10 grams chronic shallow ulcer which slowly spreads from taken whilst fasting. Trichuriasis causes no the genitalia onto the adjacent skin, and may symptoms unless a massive infection exists, be implanted onto contiguous surfaces of the when colonic irritation may be caused. thighs or transported on the fingers to distant Dithiazanine iodide (Telmid, Wyeth) which areas. The disease is free from constitutional was formerly widely used against this parasites svmptoms and causes little local discomfort; has recently been withdrawn from the general its only danger lies in its simulation of epithe- market following reports in rare instances of on September 25, 2021 by guest. lioma, especially in the female,;which may lead its toxicity. Pyrvinium pamoate (Vanquin, to unnecessary irradiation or excision. The Parke Davis and Co.) should be used instead, causal organisms are readilv demonstrated by the dose for an adult being 100 mg. three biopsv and the treatment with streptomycin is times daily for 5 days. rapidly successful. Though ancvlostomiasis was once rife in the Cornish tin mines, one can scarcely visualise Intestinal Infections and conditions in England to-day suitaible for such Intestinal infections among immigrants are of transmission. Ancylostomiasis, though it rarely importance when such persons seek employ- causes anaemia in the well-nourished European, ment as food handlers. Asymptomatic passers of is a potent cause of iron depletion in immigrants cysts of Entamoeba histolytica are not from the Tropics, especially in women on commonly found among coloured workers, and whose iron stores a further drain falls in preg- October, 1965 WALT.ERS: Infections of Immigrants 587 Postgrad Med J: first published as 10.1136/pgmj.41.480.584 on 1 October 1965. Downloaded from nancy. Since a single worm may abstract from a lateral spine in the urine or in biopsy material 0.05 to 0.2 ml. of blood daily, a modest load removed from the bladder, while the schisto- of 100 worms would cause a loss of between soma complement fixation reaction wilil be 5 and 20 ml.: haemoglobin being a poor source positive. (This very useful test is carried out of iron available for re-absorption, iron only in laboratories which specialise in deficiency is readily induced. Of the two human tropical disease, such as the Hospital for , is the Tropical Diseases, London). Infection with larger and more avid, occurs throughout Africa, smaller but more deeply buried in the crypts in Brazil and in some of the Lesser Antilles. of the duodenal mucosa, where it is less acces- The symptoms are more subtle than those sible to vermifuges. The least toxic drug avail- produced by S. haematobium, as the brunt of able and the most convenient for general use the damage falls on the colon and liver. In is bephenium hydroxynaphthoate (Alcopar, Europeans the onset may be marked by systemic Burroughs Wellcome and Co.) which is dis- disturbance, diarrhoea with blood and mucus, pensed in granular form. A single dose of 5 g. and tender enlargement of the liver and spleen. may be given after an overnight fast even to an The disease may be the cause of chronic ill anaemic, emaciated child, but for complete health, failure of growth and hepatospleno- eradication of the infection in an adult, this megaly in children. In those whose infection dose should be repeated daily for four days. dates from childhood a frank cirrhosis of No purgation is required. portal type may be found in adult life, while Strongyloidiasis, like ancylostomiasis, may on sigmoidoscopy multiple papillomata may be cause duodeno-jejunal irritation when the in- demonstrated; in those, malignant metaplasia fection is very heavy and may occasionally may ultimately ensue. The treatment of schisto- Protected by copyright. cause a frank malabsorption state, but its most somiasis is protracted and requires the use of important manifestation is the peculiar rash trivalent antimony compounds by injection. produced by the wandering larva which arises Since these are all potent myocardial toxins, from auto-reinfection. The ova hatch in the experience and care are called for in their use. intestine and within the colon itself the non- It is wise to refer patients suffering from infective rhabditiform larvae may change into to a hospital which specialises the penetrative filiform larvae which re-enter in the treatment of tropical disease. the tissues. Their passage beneath the skin causes a linear urticarcial wheal, like a whip- lash, which is very irritant. Such lesions are The filarial diseases complete the list of in- often encountered among former Far East fections likely to be encountered in immigrants. prisoners-of-war, in whose bodies the parasites Infection with is en- have managed to perpetuate themselves for over countered throughout the tropical belt, with

20 years. Telmid having fallen into disrepute, its highest endemicity in British Guiana-600/, http://pmj.bmj.com/ Vanquin should be used as for triohuriasis, but of the inhabitants of Georgetown, the capital, a very promising new drug, thiabendazole, carry this parasite. Multiple infections from widely used as an anthelminthic in sheep, is childhood are necessary in order to produce the at present under clinical trial in man. lymphatic obstruction which is the basis of the symptomatology, at least five years are required Schistosomiasis for the disease to manifest itself and European Schistosomiasis is often encountered in im- intruders into endemic areas very rarely re- migrants from West and East Africa. In per- ceived sufficient infective bites to acquire the on September 25, 2021 by guest. sons from these areas any urinary symptoms disease. Fever with recurrent inguinal lymph- should arouse a suspicion of infection with adenopathy, lymphoedema of the leg or genitalia S. haematobium. Frequency of micturition with and chyluria are the usual manifesta-tions. Re- terminal haematuria characterise the early current epididymitis, funiculitis and hydrocele stages, when later the bladder becomes contrac- should also make one suspicious of this dis- ted frequency becomes more marked and hydro- ease, which may be confirmed by the demonst- nephrosis and hydrourdter, due to fibrosis at the ration of sheathed microfiliara in the peripheral urtero-vesical junction, tend to develop. Second- blood taken between midnight and 2 a.m. The ary infection then supervenes with disastrous leucocyte count will show a high eosinophilia results and malignant changes may develop in and the filaria complement fixation test will be the bladder wall. The diagnosis is estalblished positive. Treatment is by the use of diethyl- by the presence of the characteristic ova with carbamizine (Hetrazan or Banocide, 50 mg.), 588 POSTGRADUATE MEDICAL JOURNAL October, 1965Postgrad Med J: first published as 10.1136/pgmj.41.480.584 on 1 October 1965. Downloaded from in a dosage of 3 mg. per kg. body weight three in the aqueous humour when the eye is times daily for 21 days. examined with the corneal microscope. Treat- West Africans particularly are liable to com- ment with Banocide is usually accompanied by plain of symptoms of two filarial diseases a brisk allergic reaction and should be carried which are prominent in tropical Africa. These out in a special tropical diseases centre. Euro- are loiasis and . The not infre- peans returning from tropical Africa often quent statement that the patient has got a harbour one or both of these filarial worms. worm moving under his skin may literally be The last filarial disease worthy of mention is true, for the adult moves freely in the dracontiasis, due to the invasion of the sub- subcutaneous tissues and fascial planes. While cutaneous tissues by the female worm, Dracun- crossing the bridge of the nose, the malar culus medinensis. Since the infection is region, the globe of the eye or the tarsal plate acquired by drinking water containing num- beneath the conjunctiva, it may be visible and bers of water-fleas (Cyclops) containing the can be removed under local anaesthetic. Else- larvae of the worm, the disease in this country where, probalbly through damage by pressure is likely only to be found among immigrants of resulting in the release of allergens, the pre- the labouring classes from the Tropics, exclud- sence of the worms is revealed by the develop- ing the New World. After fertilisation of the ment of patches of giant urticaria, which female in the tissue spaces the male worm dies subside usually after a few hours, but may but the female may grow to 16 inches in length persist for three days. These are called Calabar and when gravid may reach the dimensions of swellings and the usual sites of their appearance a large earthworm. Wandering through the are the forearms, dorsum of the hands and the tissue planes towards the ankles the worm region of the ankles. Exertion frequently pre- causes no reaction until the feet are immersedProtected by copyright. cipitates their onset. The diagnosis is easily in water, when she secretes a proteolytic confirmed by examination of a thick film of enzyme which raises a blister into which she blood stained with Leishman's or Geimsa's protrudes. When the blister burst larvae are stain, in which the characteristic sheathed discharged in vast numbers as a milky fluid. microfilaria will be found: these have a diurnal The female worm can then be grasped and periodicilty. Treatment is with Banocide as for slowly withdrawn by winding on a match stick, infection with W. Bancrofti, though a 10 days' the whole operation taking several days. If the course will suffice. Onchocerciasis, due to the worm can be palpated it may be removed worm, , is characterised by whole through an incision made across it, by irritant skin lesions, sometimes associated with gentle traction with an aneurism needle. Death conjunctival irritation and the development of of the worm is usually followed by infection of patchy, "nummular" keratitis. Painless sub- its track, leading to cellulitis. If untreated, this cutaneous nodes, commonly situated below the may cause extensive peri-articular fibrosis with iliac crests or the upper thigh, reveal the pre- severe dysfunction of the ankle joint. http://pmj.bmj.com/ sence of the adult worms which may remain Immigrants from the Tropics often have a in one site for several years in an intricately limited knowledge of English and describe a coiled mass surrounded by fibrous tissue. wealth of improbable symptoms in quaint Microfilaria, which have no sheath, may be phraseology. Some of these, however, may well found in superficial skin biopsy sections-skin have an organic basis in an infection peculiar snips-which should be teased in normal saline to the Tropics, and it is to aid the puzzled on a tha't 'this microscope slide. When left at room physician article has been written. on September 25, 2021 by guest. temperature under a coverslip for 30 minutes, the larvae can be seen wriggling out from the of the REFERENCES edges specimen. Microfilariae may be JOPLING, W. H.: Personal Communication. -obtained in a similar manner from conjunctival MAEGRAITH, B. G. (1963): Unde Venis?, Lancet i, snips and may be seen on occasion swimming 401.