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Wallrauch, C; Grobusch, MP; Kuhn, W; Brunetti, E; Joekes, E View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by LSHTM Research Online Blard, S; Tamarozzi, F; Bustinduy, AL; Wallrauch, C; Grobusch, MP; Kuhn, W; Brunetti, E; Joekes, E; Heller, T (2015) Point-of- Care Ultrasound Assessment of Tropical Infectious Diseases{A Re- view of Applications and Perspectives. The American journal of tropical medicine and hygiene, 94 (1). pp. 8-21. ISSN 0002-9637 DOI: https://doi.org/10.4269/ajtmh.15-0421 Downloaded from: http://researchonline.lshtm.ac.uk/2964386/ DOI: 10.4269/ajtmh.15-0421 Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: http://creativecommons.org/licenses/by-nc-nd/2.5/ Am. J. Trop. Med. Hyg., 94(1), 2016, pp. 8–21 doi:10.4269/ajtmh.15-0421 Copyright © 2016 by The American Society of Tropical Medicine and Hygiene Review Article: Point-of-Care Ultrasound Assessment of Tropical Infectious Diseases—A Review of Applications and Perspectives Sabine Bélard,* Francesca Tamarozzi, Amaya L. Bustinduy, Claudia Wallrauch, Martin P. Grobusch, Walter Kuhn, Enrico Brunetti, Elizabeth Joekes, and Tom Heller Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George’s University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom Abstract. The development of good quality and affordable ultrasound machines has led to the establishment and implementation of numerous point-of-care ultrasound (POCUS) protocols in various medical disciplines. POCUS for major infectious diseases endemic in tropical regions has received less attention, despite its likely even more pro- nounced benefit for populations with limited access to imaging infrastructure. Focused assessment with sonography for HIV-associated TB (FASH) and echinococcosis (FASE) are the only two POCUS protocols for tropical infectious dis- eases, which have been formally investigated and which have been implemented in routine patient care today. This review collates the available evidence for FASH and FASE, and discusses sonographic experiences reported for urinary and intestinal schistosomiasis, lymphatic filariasis, viral hemorrhagic fevers, amebic liver abscess, and visceral leishman- iasis. Potential POCUS protocols are suggested and technical as well as training aspects in the context of resource- limited settings are reviewed. Using the focused approach for tropical infectious diseases will make ultrasound diagnosis available to patients who would otherwise have very limited or no access to medical imaging. INTRODUCTION POCUS in resource-constrained settings provides the addi- tional benefit that it is frequently the only diagnostic imaging Ultrasound (US) has been used to aid diagnosis and to modality available.9,10 guide therapy in a large number of tropical infectious diseases 1 This review first describes the development and applica- for a long time. During the past two decades, technological tion of “focused assessment with sonography for human advances have improved image quality and significantly immunodeficiency virus (HIV)–associated tuberculosis (TB)” – reduced the size and price of US equipment. As a result, US (FASH),11 16 which is the most widely studied and implemented has been established as a point-of-care test in clinical deci- application of POCUS in infectious diseases to date. Sub- sion making and for procedural guidance in various medical 2 sequently, other infectious diseases, endemic in tropical or specialties. Point-of-care ultrasound (POCUS) is one of the resource-limited settings and accounting for significant mor- few novel diagnostic tools to which the criticism of inflation- 3 bidity and mortality in affected populations and for which ary use of the term point-of-care does not apply. Emergency POCUS has been investigated or for which POCUS may be medicine (EM) physicians have pioneered and greatly a potential diagnostic tool, are reviewed and discussed. In advanced the point-of-care application of US. Today, the view of the required focused approach of POCUS, it is impor- “ ” focused assessment with sonography for trauma (FAST) tant not only to define diagnostic criteria and test accuracy for protocol is not only well recognized as a standardized diag- each disease, but also to identify the target population in which nostic test in emergency departments, but also constitutes an 4–7 the diseases of interest are highly prevalent and for whom integral part of diagnostic algorithms and EM training. POCUS will therefore be valid and most beneficial (e.g., HIV/ The fundamental difference between POCUS and conven- TB coinfection in South Africa, echinococcosis in rural Argentina, tional US examination is that POCUS is performed by the or the Kenyan Turkana region). Finally, technical and teach- treating physician who aims to answer simple, usually binary ing considerations are discussed. questions relevant to immediate patient management (e.g., “Is there a pleural effusion, yes or no?”). POCUS is not a com- 8 prehensive US assessment. Diagnoses for which POCUS is FOCUSED ASSESSMENT WITH SONOGRAPHY suitable should fulfill two criteria: 1) diagnosis must be rele- FOR HIV/TB vant to consecutive treatment decision making and 2) diagno- sis must be easily and accurately recognizable by physicians TB is one of the most frequent opportunistic infections applying US without the necessity for extended US training. in HIV patients living in tropical countries and constitutes 17 Whereas patients’ benefit from POCUS in affluent settings is an immense problem in sub-Saharan Africa and beyond. mainly a reduced time to diagnosis and further management, Extrapulmonary TB (EPTB) is seen more frequently in immu- nocompromised patients and is more difficult to diagnose than pulmonary TB. Disseminated TB is a major cause of death in patients with HIV.18 Clinical symptoms are fever, weight loss, *Address correspondence to Sabine Bélard, Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, and night sweats, possibly with cough, shortness of breath, or Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: sabine other focal symptoms; frequently, cardinal signs and symptoms [email protected] are less clearly evident in HIV coinfected individuals. 8 TABLE 1 Summary of reported experiences of POCUS assessment of tropical infectious diseases Disease (protocol) Population Clinical symptoms US findings Suggested action Evidence Reference – TB (FASH) Africa (particularly Fever Enlarged hypoechoic lymph nodes Do sputum smear exam Well described 11 15,127 southern Africa), Weight loss Micro-abscesses in spleen and/or liver Start empirical TB treatment and widely used Asia, and South Cough Pleural effusion Test for HIV if not done in South Africa America with high Abdominal symptoms Pericardial effusion previously and treat HIV/TB coinfection (diarrhea, pain, and Ascites accordingly prevalence abdominal distension), shortness of breath Hypotension POINT-OF-CARE ULTRASOUND IN TROPICAL MEDICINE – Echinococcosis Sheep farming Symptoms depend Appearance depends on cyst Stage-specific treatment of FASE implemented 33 36,40,43 (FASE) populations, on cyst’s size, number, stage (WHO-IWGE) liver CE (WHO-IWGE) in Argentina South America, and organ affected CE1: anechoic with double wall Middle East, Jaundice CE2: honeycomb appearance, eastern Europe, Right upper quadrant pain adjacent anechoic daughter The Mediterranean, Most cases have few vesicles contained in the Central Asia, China, or no symptoms “mother” cyst’s wall east Africa CE3a: anechoic with “lily sign” (detached endocyst) CE3b: daughter vesicles within a solid matrix of the “mother” cyst CE4: inhomogeneous content with visible hypoechoic folded endocyst (“ball of wool” sign) CE5: same as CE4 with calcified wall Amebic liver Worldwide in Fever Hypoechoic, but not anechoic, round Start antibiotic e.g., Individual descriptive 46,48,49 abscess tropical countries Right upper quadrant homogenous liver lesion: possible metronidazole studies only abdominal pain amebic abscess treatment Differentials: Amebic serology a) Lesion containing gas, irregular In imminent rupture, shape: possible pyogenic abscess US-guided aspiration b) Central calcification: possible Brucella serology Brucella abscess c) Noninfectious lesion, e.g., necrotic tumor – Intestinal People in contact with Abdominal pain Increasingly wide echogenic fibrosis Refer for endoscopy for WHO guidelines 59,64 70 schistosomiasis fresh water in Africa, Intestinal bleeding around portal tracts (pattern D–F) patterns E + F available
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