Letter to the Editor

Editor, – The article by Anthony Gherardin and Jennifer Sisson (Aust Prescr 2012;35:10-4) provided a good discussion of the issues in this important clinical situation. However, there were several important omissions which I think should be commented upon.

Firstly, measles is a very important cause of fever and rash in the returned traveller, yet this is not mentioned. Many younger Australian doctors will never have seen a case of measles. However, it continues to occur in many resource-poor countries. Measles is one of the most contagious infections known in humans so the importation of even a single case is a public health emergency. It is very important to consider this diagnosis in a returned traveller with fever, respiratory symptoms and a maculopapular (or ‘morbilliform’) rash. The most rapid and accurate diagnostic test is a polymerase chain reaction on a throat swab or urine, complemented by acute and convalescent serology.

Secondly, in the diagnosis of malaria, rapid antigen tests – immunochromatographic (ICT) card tests – have become standard in nearly all laboratories in Australia, as an addition to the traditional thick and thin blood films. These tests are at least as sensitive as microscopy (by an experienced operator) for malaria caused by Plasmodium falciparum , but perform poorly for other species of malaria.

Thirdly, the NS1 antigen test for dengue fever was not mentioned. This test becomes positive earlier than serology and has excellent sensitivity and specificity. Admittedly it is only available in larger laboratories.

Finally, I think the authors have underemphasised the role of the infectious diseases physician. Most infectious diseases departments are very happy to give phone advice and, if necessary, urgent clinical review of any febrile or unwell returned traveller. Furthermore, many of the conditions listed in the article (for example schistosomiasis, yellow fever, trypanosomiasis, leishmaniasis and typhus) are rarely – if ever – seen by general practitioners and should be referred to a specialist regardless of whether or not they are atypical or severe.

Joshua S Davis
Infectious diseases staff specialist
Royal Darwin Hospital

Author's comments

Anthony Gherardin, one of the authors of the article, comments:

We thank Dr Davis for adding to the discussion and would not disagree with anything he has stated. Within the word limit constraints of the article, we could not flesh out too much and the issues raised are very relevant for general practitioners.

Nurturing a close relationship with local infectious disease physicians is also important for safe, high-quality practice.

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