TM5559: Clinical Tropical Paediatrics

Case Study Four: First presentation of a tropical ulcer in an eleven year old.

Samantha Leggett: SN12494652

22/3/2011

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Case Study Four

First presentation of a tropical ulcer in an eleven year old child

Name: Melvina

Age: 11

Sex: F

Height: 125cm

Weight: 25kg

MUAC: 17cm

Sociodemographic details: Melvina’s family live in Yabob, a twenty minute walk from the clinic. Melvina has four siblings: two older brothers, an older sister and one younger brother. Melvina goes to school and all of her immunisations are up-to-date (details from patient held health record).

Melvina reports that her siblings are all well but that her younger brother has a lesion similar to hers. Her mother is alive but was at home sick with “head pain” and her father died of “sot win” (lit. short wind/hard to breathe) some time ago -Melvina isn’t sure how long exactly. Melvina and her elder cousin say that Melvina’s mother is not employed and that she hasn’t received any schooling.

Melvina attended clinic with four of her female cousins, three younger and one older who was acting as care giver.

History and presentation: Melvina cut herself on a broken bottle three months ago. The wound has never healed, still bleeds from time to time but has never had pus present. Over time it is getting bigger, looks worse and is causing her more pain, particularly when she walks. Today is immunisation day and her younger cousins were attending the clinic for theirs - this is why she came to the clinic to be seen today. It is her first presentation at any clinic for the sore.

On examination: (see figures 1 & 2 below) a solitary oval lesion can be seen with a raised undermined border over the left Medial Malleolus approximately 2cm in diameter and approximately 1/2cm deep at the centre. Bony tenderness is present surrounding the lesion and pain is experienced on walking-Melvina wincing and limping. No associated groin pain reported but groin not examined for lymph nodes (so query lymphadenopathy present). A normal range of movement was found in the leg, ankle and foot but with pain.

Melvina’s temperature was 36.6 degrees C and she says that she has not felt feverish or unwell for the duration of the wound.

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Figure 1

Figure 2

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Diagnosis: Tropical ulcer +/- acute arthritis or osteomyelitis

Differential diagnosis: Buruli ulcer (BU) (Melvina falls into the peak age distribution bracket for BU; Papua New Guinea sees the majority of cases of BU in Oceania; some surrounding hyperpigmentation; chronic lesion; no fever; painful associated joint [1])

Tropical Ulcer

Tropical ulcer is the term used to describe ulcers occurring in (usually rural areas of) the tropics and sub-tropics that are not typical of a more definitive aetiology (e.g. Buruli ulcers, leprosy, diabetes). Tropical ulcers largely occur below the knee, are more common in women and children and are often initiated by minor trauma. The acute phase of the development of a tropical ulcer is 2-3 weeks and it will be painful during this time. Maximum size is reached at 6 weeks. Once it has developed an ulcer may heal, become chronic and stable, or it can become destructive invading soft tissues with an increased risk of the development of squamous cell carcinoma. In extreme cases amputation may be necessary. Unlike Buruli ulcer, tropical ulcers are typically painful [2, 3].

A study in Papua New Guinea (PNG) found that 46% of cases presenting with tropical ulcer were in the 5-14 year age group although with a fairly equal sex distribution. The annual attack rate within communities was 1.5% and 8.9% in primary school aged children. Additionally there was no seasonal variation in ulcer prevalence [4].

No correlation has been found between the development of an ulcer and nutritional status and the relationship between the two causes contention within the literature [4]. Systemic factors pertaining to the individual can have a significant impact upon wound healing however; malnutrition and anaemia being the most relevant in this situation. Wounds need an adequate blood supply to heal and the skin of an under nourished person will have impaired function which also impacts upon wound healing [5]. Further, anaemia with haemoglobin levels of <100g/l delays healing and <70-80g/l represents wounds that are unlikely to heal [6].

The literature fails to provide us with statistically significant relationships between nutritional status (and therefore immunity) and wound healing. However, optimal nutrition maximises the chance of proper healing and oral nutritional supplementation can play an important role. A standard multivitamin and mineral combination is recommended with extra vitamin A (10 days of 10,000-50,000 IU/day), C (up to 1g/day until the wound heals) and zinc (10 days) if deficiencies are suspected [2, 6].

Discussion

Melvina is 125cm tall which is well below the 3rd percentile of height for her age or -3 standard deviations [7, 8]. Her weight is 25kg which is midway between the 3rd and 15th percentiles on height for age or -1.5 standard deviations for age 10 [9, 10] and her body mass index (BMI or height/weight ratio) for age is less than -1 standard deviation from the median [11]. Melvina’s mid-upper arm circumference (MUAC) measures 17cm however the UN assert that MUAC is mainly relevant for the measurement of nutritional status in children aged 6 months to 5 years. There is no agreement for the measurement and

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interpretation of MUAC values outside of this range although MUAC has been used in interventions targeted at pregnant women and cut-off values may be population specific [12].

Melvina’s measurements would suggest stunting perhaps due to early childhood malnutrition or maternal factors (e.g. maternal malnutrition, anaemia during pregnancy, malaria during pregnancy leading to low birth weight) and are indicative of an ongoing poor nutritional status. Anaemia of <80g/l is common in PNG (pers. com with MO at Modilon General Hospital, Madang) and it may therefore be possible that Melvina falls into this category. Given the suggestions in the literature for the stages of development of a tropical ulcer it may be assumed that Melvina has had the lesion for less than the three months that she thinks. If this is the case and the ulcer is still in the acute phase, with adequate wound care and nutritional supplementation it may be possible to stop it from becoming a chronic wound with its related risks.

After her consultation with one of the clinic nurses Melvina was prescribed the following for her lesion: five days of oral Amoxicillin, 500mg Paracetamol, Albendazole two tablets stat and was given Cetrimide/Chlorhexidine topical ointment to apply to the lesion with non-sterile gauze squares to dress it with. The nurses did not clean the wound or dress it, nor did they provide any demonstration or education as to how this should be done. Melvina was advised to return to the clinic the following week if the sore had not healed.

Rationale for choice of anti-microbial therapy was discussed with the clinic nurses and in this instance the nurse attending to Melvina said that she would have liked to have given Flucloxacillin but they didn’t have the correct strength. Antibiotic resistance was also discussed as the student is aware that there is much resistance to Amoxicillin in PNG. From personal experience with wounds in PNG, specifically three that were acquired in the Madang area, in practice Cloxacillin is actually more effective than Flucloxacillin. The World Health Organization [13] advise Cloxacillin 25-50mg/kg PO QDS for at least five days in the treatment of tropical ulcers and assert that inappropriate and irrational use of antimicrobial medicines provides favourable conditions for resistant microorganisms to emerge, spread and persist [14].

A further discussion between JCU students and the clinic nursing staff ensued: It was respectfully asked whether they thought that an x-ray would be appropriate given the location and duration of the ulcer and the location and severity of the pain that Melvina was experiencing. The nurses replied that they would maybe send her for one if she returned the following week and the ulcer wasn’t healed. It could however be challenged that if it took three months for the child to present to a clinic in the first instance, it is unlikely that she will return a week later.

With further reference to wound management, the International Federation of Dermatology [3]recommend that tropical ulcers are cleansed daily with water clean enough to drink (e.g. boil for fifteen minutes and then leave to cool). The application of a topical antibacterial should be reserved for non-healable wounds, or those in which the local bacterial burden is of greater concern than the stimulation of healing. Studies have identified that the application of topical antiseptics in wounds with the ability to heal can damage healthy tissues [15]. In Melvina’s case both cetrimide and chlorhexidine

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have good activity against both Gram-positive and –negative organisms although cetrimide is highly toxic to tissue; chlorhexidine is less so.

After cleansing, the application of a clean non-adherent dressing is recommended (adherent dressings will stick to the wound and cause trauma to granulation tissue when removed). These dressings don’t need to be expensive-petroleum jelly impregnated gauze or saline soaked gauze will suffice [3]. Green papaya is also advocated in the management of sloughy ulcers [2] and the author has had success in this method personally.

Further, tetanus is a complication of tropical ulcers [2] and WHO [13] advise a tetanus toxoid booster if the child has had active immunization or anti-tetanus serum if it is available and then commencement of a course of tetanus toxoid vaccine. Melvina’s immunizations are up-to-date and she should have therefore received a tetanus toxoid booster. This was not given.

The ultimate goal of wound management is the prevention of a deteriorating wound, the promotion of rapid healing and the prevention of wound related disability; goals which can only be accomplished with timely, appropriate and quality intervention. The basic fundamentals of wound management can address tropical ulcers: enhancing systemic factors (e.g. nutritional supplementation), protecting the wound from trauma (e.g. correct dressings), debridement if necessary, control of infection (e.g. correct cleansing techniques, anti-microbial therapy and tetanus toxoid therapy), moist wound care and control of oedema if applicable [3]. Melvina’s care does not seem to demonstrate many of these variables.

Health Seeking Behaviour

As previously mentioned, Melvina stated that she had the wound on her ankle for three months and that this was her first visit to a clinic to seek treatment for it. Given her signs and symptoms the literature would suggest that the ulcer may only have been present for six weeks at the most. However, either of these time frames represents a delay in seeking care. A discussion regarding health seeking behaviour is therefore relevant.

Health seeking behaviours can contribute to a delay in seeking care thus prolonging morbidity, likely increasing the severity of the illness and increasing the risk of mortality [16]. Howlander & Bhuiyan [17] report that one of the most important reasons for high rates of childhood mortality is the limited use of health services by mothers, with a complete absence of health care sought in 23% of child deaths [18]. A diversity of factors has been demonstrated to contribute to poor care seeking behaviours [16, 18-22]:

Lack of physical accessibility (Tinuade et al [16] found that even when families did live close to health facilities, only 50% utilised them)

Cultural perceptions and beliefs (e.g. witchcraft) Large family size Type of illness Monetary cost (of treatment, loss of earnings, fares for public transport) Frustrating routines at health facility Hostile attitudes of health workers

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Knowledgeability and skills of health care workers Availability of resources at the health facility Non-recognition of severity of illness by mothers Level of maternal education (maternal literacy level is one of the two most significant

determinants of health care utilisation) Poor socio-economic status is the single most pervasive indicator

Access to affordable health care is limited in many low income countries and this is true of Papua New Guinea. Due to this people tend to largely rely on self-medication and buy antibiotics for example from pharmacy staff, street vendors or markets [23]. The cost of treatment and the availability of money to pay for it seem to be important determinants of self medication versus seeking care at a health facility. If symptoms are perceived to be non-threatening families can afford to wait for longer to seek care and chronic conditions in particular can result in a lack of focus for action; sometimes needing prompting by others before care is sought [22]. Self medication purchased from pharmacies or stores has been shown to be a significant contributing factor to delays in seeking conventional health care [21]. These variables could go some way towards explaining why care seeking was delayed in this instance.

In rural communities in particular, cultural beliefs and practices can often lead to self-care, home remedies and consultation with traditional healers. These determinants are more common amongst women, both for themselves and their children [19]. A fear of the power of witchcraft within communities contributing to a delay in health care seeking is also highlighted; a belief that traditional healers know how to heal a disease caused by witchcraft, and a fear of reprisals if conventional health care is sought to heal the disease are implicated. Traditional healers have been shown to compound this belief. The use of traditional medicine before presenting at a health facility is an important factor in causing delay [21].

Level of education and poverty emerge as the two most significant determinants of health seeking behaviour. Some education correlates with a lower likelihood of choosing self-treatment and a higher probability of seeking care at a health centre. However, Tinuade et al [16] found no influence on the perception of illness severity by maternal education level. Conversely, poverty reduces the odds of seeking conventional health care and increases the likelihood of using self-treatment with medication bought from a pharmacy/store or traditional healer [20]. Howlander & Bhuiyan [17] demonstrate that among socio-economic indicators mothers with at least primary level education is the most powerful variable for reducing child mortality.

Links between education level and health care seeking behaviour point to the need to promote health literacy as a capacity building activity within communities. The World Health Organization [18] asserts that appropriate care-seeking is of particular importance in areas where access to health services is limited. In these areas caregivers (e.g. parents or other family members) would benefit most from being able to discern serious from non-serious illness and knowing when care needs to be sought. The health education of mothers and training of community health care workers is implicated; families have the major responsibility for caring for their children and so partnership is key for success. Information,

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education and communication campaigns should address local health care beliefs (see figure 3) and efforts should be made to work with health care providers outside the formal health care system [20].

In addition to capacity building within the field of health literacy in hard to reach communities, it is advocated that all families, wherever they live and whatever their socioeconomic status and education level, should know how to and have adequate support to care for their children, know how to prevent and respond to common illnesses and should know when and where to seek appropriate care [18].

Further, Chibwana et al [24] demonstrate a need to address the real and perceived barriers to health seeking behaviour in all communities and assert that the empowerment of women is key. Improved care seeking behaviour and maternal education is likely to result in a contribution to decreasing the worldwide burden of child mortality and morbidity [18].

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Figure 3

An example of how IEC materials can incorporate cultural beliefs.

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References

1. Portaels F, Silva MT, Meyers WM. Buruli Ulcer. Clinics in Dermatology 2009; 27: 291-305.2. Gill GV, Beeching NJ. Lecture Notes on Tropical Medicine. 5th ed. Oxford: Blackwell Science;

2004. 3. International Federation of Dermatology. Management of Tropical Ulcer [cited 2011 February

24] Online.4. Robinson DC, Adriaans B, Hay RJ et al. The clinical and epidemiological features of tropical ulcer

(tropical phagedenic ulcer). International Journal of Dermatology 1988; 27 (1): 49-53.5. World Health Organization Wound and Lymphoedema Management 2010 (cited 2011 February

24) Online6. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutrition in Clinical

Practice 2010; 25 (1): 61-68.7. World Health Organization height-for-age girls 5-19 years (percentiles) [cited 2011 February 24];

Online.8. World health Organization height-for-age girls 5-19 years (z-scores) [cited 2011 February 24];

Online.9. World Health Organization Weight-for-age Girls 5-10 years (percentiles) [cited 2011 February

24]; Online.10. World Health Organization weight-for-age girls 5-10 years (z-scores) [cited 2011 February 24];

Online.11. World Health Organization BMI-for-age Girls 5-19 years (z-scores) [cited 2011 February 24];

Online.12. United Nations System Standing Committee on Nutrition. Mid-Upper Arm Circumference

(MUAC) [cited 2011 February 24]; Online. 13. World Health Organization. Pocket book of hospital care for children. Guidelines for the

management of common illnesses with limited resources. Geneva: WHO; 2005 [cited 2011 January 10]; Online.

14. World Health Organization Antimicrobial resistance Factsheet No 194 February 2011 [cited 2011 February 25]; Online.

15. World Health Organization. Essential Intervention No. 2: Wound Management [cited 2011 March 22]; Online.

16. Tinuade O, Lyabo AI, Durotoye O. Health-care-seeking behaviour for childhood illnesses in a resource-poor setting. Journal of Paediatrics and Child Health 2010; 46: 238-242.

17. Howlander AA, Bhuiyan MU. Mothers’ Health Seeking Behaviour and Infant and Child Mortality in Bangladesh (Demographers’ Notebook). Asia Pacific Population Journal 1999; 14 (1): 59-75 [cited 2011 March 15] Online.

18. Hill Z, Kirkwood B, Edmond K. Family and community practices that promote child survival, growth and development. A review of the evidence. Geneva: WHO; 2004 [cited 2011 March 15] Online.

19. Shaikh BT, Hatcher J. Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. Journal of Public Health 2004; 27 (1): 49-54.

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20. Ahmed SM, Tomson G, Petzold M et al. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh. Bulletin of the World Health Organization 2005; 83 (2): 9-18 [cited 2011 March 11] Online.

21. Mulder AA, Boerma RP, Barogui Y, et al. Healthcare seeking behaviour for Buruli ulcer in Benin: a model to capture therapy choice of patients and healthy community members. Transactions of the Royal Society of Tropical Medicine and Hygiene 2008; 102: 912-920.

22. Amuyunzu-Nyamongo M, Nyamongo IK. Health seeking behaviour of mothers of under-five-year-old children in the slum communities of Nairobi, Kenya. Anthropology and Medicine 2006; 13 (1): 25-40.

23. Kristiansson C, Reilly M, Gotuzzo E et al. Antibiotic use and health-seeking behaviour in an underprivileged area of Peru. Tropical Medicine and International Health 2008; 13 (3): 434-441.

24. Chibwana AI, Mathanga D, Chinkhumba J et al. Socio-cultural predictors of health-seeking behaviour for febrile under-five children in Mwanza-Neno district, Malawi. Malaria Journal 2009; 8: 219-227.

Bibliography

1. Mortenson G, Relin DO. Three Cups of Tea. One man’s mission to promote peace...one school at a time. London: Penguin Books Ltd; 2007.

2. Mortenson G Stones into Schools. Promoting peace through education in Afghanistan and Pakistan. London: Penguin Books Ltd; 2009.

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