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Multiple Pathology

There is a strong possibility that any patient seen in the tropics will suffer from more than one disease (Fig. 44.1). Moreover, the sickness that brings him or her to the hospital may not be the most clinically significant problem. Multiple parasites are to be expected: not just two or three different parasites, because as many as 24 varieties have been recorded as the average in some villages in Africa. In Borneo a few years ago, 97% of over 2000 stool specimens contained evidence of internal parasites (usually multiple), Trichuris trichiura being the most common (90%), with Ascaris (76%) and hookworm (60%) next in frequency. It is estimated that nearly 100% of all rural Indonesians are infected with at least one parasite. Malaria, schistosomiasis, and amebiasis are often background problems of little immediate significance. They are the cause of chronic ill health, anemia, and malnutrition but are not necessarily the reason for the current illness.

The "nontropical" radiologist has been trained to tidy all the abnormal findings into one etiological basket; the tropical patient, wherever seen, does not always permit this. Trying to decide what causes a particular clinical or radiological abnormality adds to the interest of tropical medicine.



Fig. 44.1 A-E. One man's problems! An example of multiple diseases, only one of which brought the patient to hospital. He was an elderly man complaining of persistent cough and loss of weight: he was found to have chronic but active tuberculosis, involving both lungs but particularly the right. The chest radiograph (A) also showed multiple calcified cysticerci and lytic destruction of the fifth left rib anteriorly and tenth right rib posteriorly. Further radiographs (B,C) showed severe chronic osteomyelitis in the lower half of each humerus with partial fusion and perhaps subluxation of both elbows. There is an old healed fracture of the right humerus and a pathological fracture in the lower end of the left humerus. Similar chronic infectious changes were observed (D) in the upper end of the right femur, with loose fragments of bone in the soft tissues, opaque injections into the buttock, and more calcified cysticerci. A lateral radiograph of the skull (E) showed further chronic osteitis spreading across the entire vault. All the skeletal lesions were syphilitic and this accounted for the opaque injections in his buttock, from previous treatment. He also had schistosomiasis and multiple intestinal parasites. He was not concerned about his skeletal lesions; he had adjusted to his stiff elbows, but he was bothered by his cough!

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