All posts by michael

“The Great Imitator”

There are many causes of a lymphocytic CSF, both microbiological and non-microbiological. Here is a quick and non-exhaustive summary:

  • Enteroviruses- probably the most common cause, in most parts of the world.
  • Herpes Simplex Virus (HSV)- one of the most important to diagnose/exclude as HSV encephalitis is associated with a high mortality rate.
  • “Lots of other viruses…”- There are many viruses which can cause a lymphocytic CSF, too many to list really. How many you test for depends on how much money your lab has, and how sick the patient is.
  • TB- Look for the classical risk factors and a more sub-acute presentation.
  • Cryptococcus- Usually in immunocompromised, particularly HIV. Remember cryptococcal antigen has essentially replaced Indian Ink stain as a diagnostic test.
  • Leptospirosis- Other systems (i.e. renal, respiratory) usually involved.
  • Non-infectious- Autoimmune, malignancies, drugs can all be causes of a lymphocytic CSF.

and the list goes on…

But one cause of a lymphocytic CSF that I have not mentioned is one that is often forgotten about.

Syphilis.

Syphilis is sometimes called “The Great Imitator” because of the diversity of clinical syndromes it can cause. In the words of William Osler “Those who know syphilis, know medicine.”


William Osler

And with the massive increase in syphilis over the past few years in New Zealand (and many other parts of the world), that syndrome diversity is starting to reveal itself…

In the past two years, I have personally seen 5 cases of lymphocytic CSF due to neurosyphilis. Sometimes it has been anticipated, in others it has been completely unexpected.

So all cases of unexplained lymphocytic CSFs should really be getting treponemal serology performed on serum. A lymphocytic CSF and positive syphilis serology is neurosyphilis until proven otherwise. On those with positive syphilis serology, neurosyphilis can be confirmed by looking for VDRL and FTA in the CSF.

Neurosyphilis does not just present with an acute/subacute meningitis picture. Tertiary neurosyphilis can present with psychiatric or dementia symptoms (I have seen one case of neurosyphilis presenting as dementia). Again these cohorts of patients should all be screened for syphilis. 

Syphilis can affect the neurovasculature and present as a CVA (stroke). In the same manner as above, all patients who present clinically with stroke should get syphilis serology.

Yes, syphilis is indeed the great imitator.

We do about 25000 syphilis serology tests a year at my lab. When I started at my current position 12 years ago, we would maybe see 1 case of syphilis every month. Now we see 5 or 6 cases a week…

Syphilis is a fascinating disease, one of my favourites. But because it imitates so many other conditions, it is important to always think about it, so it isn’t missed. Missing cases of syphilis can have catastrophic consequences down the line…

Michael

 

“Flu in Kathmandu”

When I was offered the chance to go to a WHO influenza meeting in Kathmandu, I grabbed it with both hands. Such opportunities certainly don’t come by every day…

However the trip to Nepal did not get off to the best of starts.

On the flight to Kathmandu, I started to get toothache. By the time we landed I was in agony. The pain was compounded by the fact that my suitcase didn’t make the connection at Singapore. Ouch!

Things could only get better…

However my initial impressions of Kathmandu did little to lift my spirits. There were three power cuts in the first 24 hours, apparently a hangover from the 2015 earthquake. I had to pass on coffee in my hotel room as the tapwater had a distinct greeny brown tinge to it. I then attempted to do some initial exploration of the city on foot, but crossing roads in this city is not for the faint-hearted! Eventually fatigue and my nerves got the better of me and I retreated to the safer confines of my hotel room, wondering just what I had got myself into…

But things did eventually improve (as they almost always do!). The conference started the next day and it was good to focus for a change on just one microbiological subject (influenza) for two and a half days, as this allowed the acquisition of some in-depth knowledge. It was also good to speak to representatives from countries that I have very little knowledge of and have certainly never met anybody from before , i.e.  Timor Leste, Mongolia, Bhutan. The Nepalese people themselves were very friendly and as most of them knew a little bit of English, it was easy to strike up a conversation.

And my suitcase eventually turned up, albeit the day before I was due to leave (carry-on bag next time!). As for my toothache, the hotel concierge kept me going with a steady supply of paracetamol, which took the edge off the pain and allowed me to function. I fear a visit to the dentist will be required though on return to NZ.

The highlight of the whole trip was the final day visit of local hospitals, public health laboratories, and the Nepal National Influenza Centre. This was a fantastic opportunity to meet local laboratory professionals, and to discuss what particular challenges they faced in a sometimes challenging environment. I was extremely impressed at the systems they had in place.


“Lab and hospital tour in Kathmandu”

So despite the challenges the trip turned out to be hugely educational, both in an academic and cultural sense. I learnt a good deal about Influenza, and even more about Nepal. It is very different to New Zealand! I look forward to going back there one day,  hopefully to do some trekking in the Himalayas.

And I have made a new resolution:- to attend at least one microbiology conference a year in a place I have never been to before, even if I have to pay for it myself.

Michael

 

“Going on leave…or not?”

When an “Out of office autoreply” is received into your inbox, it is increasingly common to get something like this…

“Please note I am on annual leave for the next two weeks. I will only be checking my emails intermittently.”

Hmmm….

There are two reasons why this “halfway house” is a bad idea, regardless of your responsibilities or seniority. Firstly, by checking your emails at all, you are not getting away from work completely. By checking your emails, you will never get work out of your mind, the things in the laboratory which were stressing you will still be stressing you, defeating the purpose of leave in the first place. Time is a great healer…

And secondly, by checking emails whilst on leave, you are giving the perception of distrust for those colleagues who are covering for you. Leave them to it. They are more than capable.

There is not much that cannot wait in the microbiology laboratory. And anything that cannot wait, should never be sent by email.

With smartphones, the temptation to keep in touch with work whilst on leave is almost overwhelming. Don’t do it! Switch the notifications off. Even better disconnect the email app from the server. Remove yourself from temptation, you will still have a job to go back to when you return, and people won’t think any less of you because you have been totally incommunicado during your holidays. In fact they may well have a grudging respect….

Enjoy your holidays, spend quality time with your family, and forget all about work for a while. You will likely come back rejuvenated, and ready to provide value to your microbiology laboratory.

Trust me, the sky will not fall because you are not there.

So the next time you are on leave, put something like the following on your out of office autoreply.

“I am on leave until date X. Person Y is covering for me. If necessary I will get back to you on my return.”

Take leave like you mean it!

Michael

p.s. Worried about that mountain of emails that awaits you on your return? Don’t be. Give yourself 1 hour exactly to clear the bulk of your inbox. Be brutal, ruthless and without remorse. Many of the email topics will have been sorted, or forgotten about. You will soon work out which emails are actually important, which in reality is about 1%!