Viet Nam - Quang Ngai: Undiagnosed illness, 26 fatalities since April 2011

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Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI- unspecified rickettsia identified

http://www.promedmail.org/

Published Date: 2012-04-27 14:37:37
Subject: PRO/EDR> Undiagnosed illness - Viet Nam (04): (QG) rickettsia susp, RFI
Archive Number: 20120427.1116144

UNDIAGNOSED ILLNESS - VIET NAM (04): (QUANG NGAI) RICKETTSIA SUSP. REQUEST FOR INFORMATION
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A ProMED-mail post

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ProMED-mail is a program of the
International Society for Infectious Diseases

http://www.isid.org

Date: Wed 25 Apr 2012
Source: Quang Ngai Province website [edited]

http://www.quangngai.gov.vn/quangngai/english/news/2012/73381/

The SGGP (Sai Gon Revolution Newspaper) quoted Quang Ngai Health Department director Mr Pham Hong Phuong as saying in the evening of Tuesday (24 Apr 2012) that a rickettsia virus [rickettsia are bacteria, not viruses] was found to be the cause of the mystery disease in the mountainous district, adding that 14 out of total 26 blood sample tests on Ba Dien infected residents in Ba To district were positive for rickettsia [bacteria].

Mr Phuong said 30 per cent of the tested samples have found that erythrocytes that are small and fragile, that could have caused death in patients easily, and added that he has recently requested Quang Ngai Government to equip the provincial general hospital with ultrafiltration and special medicines to deal with the historical disease.

Quang Ngai has reported that so far at least 19 people have been killed and 172 have been injured by the disease, which is being closely watched by the Government of Viet Nam and also the World Health Organization, which has recently released information on its website to readily help Viet Nam deal with the strange disease. Currently, Quang Ngai Government has been making more efforts in providing medical and financial assistance to treating infected patients.

According to Mr Phuong, a special task delegation from the Ministry of Health (MoH) will [visit a 2nd time] the disease affected-mountainous region on 27 Apr 2012 in a bid to [determine the] causes of the skin disease.

Recently, 19 pupils in the other mountainous region of Son Ba Commune, Son Ha district, have been infected with another skin disease on hand, foot and face [?hand-foot-mouth disease] and they are under treatment in local health stations.

--
communicated by:
Viki Hansen-Landis, RN, MPH, CHES
Senior Medical Communications Specialist
Medical Information and Analysis
International SOS


[The news report above says that rickettsiae were identified in 14 of 26 blood samples. What test was used to accomplish this identification is not specified, nor is the rickettsial species specified. The _Rickettsia_ genus describes small obligate intracellular parasites that are maintained in animal and arthropod reservoirs and transmitted by arthropod vectors (ticks, fleas, lice, or mites) to humans.

Scrub typhus and murine typhus are likely the most common rickettsial diseases in Viet Nam (http://cid.oxfordjournals.org/conten...nt_4/S145.full). Scrub typhus, caused by _Orientia tsutsugamushi_ , a rickettsial organism, is transmitted by bite of larval mites (chiggers), which serve as both the vector and the reservoir. Rodents of (rats and mice) are common hosts for the mites. Fever, headache, lymphadenopathy, myalgias, a sore at the site of the chigger bite, and rash that is unlike the rash described in patients in the current outbreak are common. Patients with severe scrub typhus can develop multiorgan failure and disseminated intravascular coagulopathy (DIC) with hemorrhage, with mortality rates 1-30 per cent in untreated patients.

Murine typhus is a fleaborne rickettsial disease caused by _Rickettsia typhi_. Rats are the primary animal reservoir of _R. typhi_. Humans are usually infected by contact with infected flea feces, either by inoculation into excoriated fleabites, inhalation, or ingestion. Symptoms include fever, headache, chills, vomiting, nausea, myalgias, and a rash that is unlike the rash described in patients in the current outbreak. Murine typhus usually resolves within 3 weeks, even if untreated. However up to 4 per cent of patients sick enough to be hospitalized will die from the infection.

The news report above also says that 30 per cent of the tested blood samples had erythrocytes that were small and fragile, suggesting the possibility of hemolysis, which can occur in scrub typhus with DIC. Obviously we need more information as to the way the diagnosis of rickettsial infection was made.

Quang Ngai is a Vietnamese province located in the South Central Coastal region along the South China Sea, 883 km south (549 mi) of Hanoi and 838 km (521 mi) north of Ho Chi Minh City (http://en.wikipedia.org/wiki/Quang_Ngai_province). The province has a large plain along the coast and in the center of the province and has mountains and hills in the west. Ba To is a rural district of Quang Ngai province with a population of 47 268 in 2003 (http://en.wikipedia.org/wiki/Ba_To_District).

A map of Viet Nam provinces can be seen at http://upload.wikimedia.org/wikipedi...ovincesMap.png. Viet Nam may also be found on the interactive HealthMap/ProMED-mail map at http://healthmap.org/r/2bxT. - Mod.ML]

[Anne]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI- unspecified rickettsia suspected - scrub typhus?

this people could have in addition : anemia ( small erythrocytes ) or other "blood" disease ( like sickle cell anemia and thalassemia ) which are frequent in vietnam, cambdoge, and Laos

http://cid.oxfordjournals.org/content/34/Supplement_4/S145.full

Before the age of antibiotic therapy, patients with scrub typhus had high mortality rates, up to 50%?60%, with a clinical course ranging from 10 to 28 days and a protracted convalescence of up to 4 months [6, 59, 60]. It often occurs in conjunction with malaria, leptospirosis, and amebiasis. Although ∼25%?50% of scrub typhus cases occur in children, most cases occur through agricultural exposure, such as in rice field workers of Thailand, Japan, or Korea and oil palm and rubber plantation workers of Malaysia [6]. The growing popularity of ?ecotourism??camping, trekking, and rafting in areas of endemicity?has resulted in this disease being increasingly reported in European and American tourists returning home [6]. Although clear descriptions of scrub typhus are found in Chinese texts of 313 A.D., scrub (miteborne) typhus was first described in the modern literature in Japan in 1810

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI- unspecified rickettsia suspected - scrub typhus?

Unsolved, yet again:

http://www.thanhniennews.com/index/pages/20120429-mold-rice-suspected-as-causing-fatal-skin-condition.aspx

Rice mold added to list of suspects in Vietnam fatal skin condition
Last Updated: Sunday, April 29, 2012 04:20:00


A felled tree used as a barrier to prevent people from entering Go Nghenh Village in Quang Ngai province. Villagers do not want to be disturbed while chasing away a ghost they believe is causing a skin condition that has killed at least 19 people.

Vietnam health officers are adding rice mold to the list of suspects as they try to solve the mystery of a fatal skin condition in a district in the central region.

At a Saturday meeting between the Health Ministry and authorities in Quang Ngai Province, it was said that many of the patients in Ba To District had eaten rice covered with fungus, the Nguoi Lao Dong newspaper reported.

Nguyen Thi Kim Tien, the health minister, said at the meeting that the ministry has ruled out microorganisms as the cause and narrowed the suspects to poisons transmitted through external contact or eating.

She said the condition is not contagious.

The ministry is studying the molded rice as well as other toxin suspects, and will try to reach a final conclusion in the next ten days. Otherwise, the ministry will seek help from the World Health Organization, Tien said.

The ministry’s experts last week found the flea-carried Rickettsia in half of the blood samples taken from the district on April 12-13, but then said the typhus bacterium did not cause the condition.

The skin condition begins with a high fever, loss of appetite and causes inflamed, thickened skin on palms and feet

It has thus far claimed the lives of 19 people among 179 affected in the district, including two new cases on April 28, a man and a woman both 35 years old.

Doctor Tran Hau Khang, director of Vietnam National Dermatology Hospital, said infected people, most of them children and young people, have their liver enzyme levels increase by 4-20 times the normal.

Le Han Phong, chairman of the district People’s Committee, said the illness responds well to treatment but patients who are not treated early can suffer liver problems and multi-organ failure.

The first infections in the district were reported last April. The condition died out by the year-end, but has returned with eight deaths between March 27 and April 5 this year. At least 29 people have been re-infected.

Last week the Ministry of Defense collected soil, water and air samples from the district to check if toxins left from the Vietnam War are causing the skin condition.

Meanwhile, many of the district's frightened residents have chosen to isolate themselves from outsiders, spooked by the visits of officials.

Reu and Go Nghenh villages, home to the patients, are not allowing outsiders to visit because the residents want to be undisturbed as they “make offerings to drive away the ghost causing the disease,” said Pham Van Vong, head of Go Nghenh village.

Pham Van Dang, the head of Reu village, was reluctant to open the gate to health experts.

“If they can get rid of the disease, they'd better do it. The more they came, the more people here have got sick. We are very scared now,” Dang told the Nguoi Lao Dong newspaper.

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

http://www.thanhniennews.com/index/pages/20120427-vietnam-quarantines-half-vacant-village-as-illness-rages-on.aspx

Vietnam quarantines half-vacant village as illness rages on
Last Updated: Friday, April 27, 2012 08:10:00

World Health Organization awaits green light to assist central village after unidentified mysterious symptoms kill 19 and afflict 171 in central district

No one has been allowed in or out of Reu Village since last Thursday.

A makeshift bamboo barrier blocks every road leading to the village in Ba To District?s Ba Dien Commune and a traditional curfew, observed in times of crisis, has kept the remaining villagers confined to their homes after sundown.

Pham Van Trach, 16, lay in a hammock in his older brother?s garden. It was easy to recognize the signs of infection on his face and arms.

?I was just discharged from the hospital. My brother?s family is still at the Quy Hoa [Hospital],? he said.

The boy, who lives with his brother?s family has survived on food donated by his neighbors during the past few days.

?We are performing rituals to dispel ghosts and appeal to the Gods to help the afflicted villagers,? said Pham Van Dang, the village patriarch.

In the past three weeks, the unidentified illness has killed 19 of the roughly 170 patients in Quang Ngai Province?s Ba To District.

The illness begins with a high fever and loss of appetite. Skin inflammation, particularly on the palms and feet, soon follow.

The first case of the unidentified illness was reported on April 19, 2011. The condition seemed to die out late last year.

This spring, the village saw 68 cases and 8 deaths between March 27 and April 5.

Colonel Dinh Ngoc Tan, head of the Military Institute of Chemistry and Environmental Sciences, told reporters that Pham Van Mai, a village elder, first saw the symptoms five years ago, around the same time the villagers had buried an unknown quantity of a ?strange chemical.?

Col. Tan said Mai has given them a map to the chemical?s burial site. No further details were provided.

Meanwhile, the Quang Ngai Health Department told Vietweek on April 24 that experts from the Health Ministry are suspecting that the condition is a tick-borne disease caused by the bacteria Rickettsia.

Fourteen of the 26 blood samples taken from residents with the skin disease symptoms at Ba Dien Commune tested positive for Rickettsia, the department said.

Vietnamese health authorities have yet to offer any proper diagnosis for the condition, which re-emerged in recent weeks.

At least 29 villagers are suffering the mysterious symptoms for the second time, suggesting that some patients are unable to build up strong immunity, following the first round of infections.

Ghost town

In the past few days, many frightened villagers have relocated. Those who remain say that the residents of surrounding communities have refused to visit them.



This student is among more than 170 residents in Quang Ngai Province who are suffering from a mysterious and fatal series of symptoms that has left 19 dead.



?Last week, a villager died but few attended the funeral. They were afraid that the ghost would seize their lives as well,? said villager Pham Van Khiem.

Like Khiem and Dang, all Hre ethnic people were given the family name of Prime Minister

Pham Van Dong (1906-2000) in 1975. Traditionally, members of tribe only carried one name.

Many of the houses in the village now stand empty as families crowd into hospitals to watch over sick relatives. Others moved to surrounding villages in fear of ?ghosts.?

?We?re trying to calm them down without having an explanation,? he said. ?We know nothing about the condition.?

Dang said the illness has totally upended life in the village. Men refuse to go to the field and many children have ceased going to class.

?Everyone is afraid that they?ll contract the disease sooner or later,? he said.

Nearly 50 patients have been admitted to the Quy Hoa National Leprosy and Dermatology Hospital in neighboring Binh Dinh Province.

Nguyen Van Duong, principal of Ba Dien Secondary School, said half of the school?s pupils stopped showing up to class in recent weeks, just a few weeks before final exams.

Meanwhile, according to the commune chairman, Pham Van Hoa, only five of 75 students continue to attend the community?s only kindergarten.

?Some of these children contracted the disease but the parents of healthy kids are too afraid to take them to school,? he said, adding that many families have simply moved to other villages.

Toxin suspected

Experts from the Ministry of National Defense gathered at Ba To District in Quang Ngai Province on April 20-21 to determine the cause of the problem.

The experts interviewed locals about their diets and possible sites of contamination.

Officials from the ministry have claimed that senior residents told them that the district once housed a US arsenal. Early this week, military scientists began collecting water and soil samples. Some suspect that toxins left over from the Vietnam War may be responsible for the recent outbreak.

Le Han Phong, chairman of Ba To District People?s Committee, said that patients who do not seek medical treatment soon after symptoms emerge can eventually suffer liver problems and organ failure.

Tran Hau Khang, director of the National Dermatology Hospital in Hanoi, said that, although the illness has yet to be identified, it does not appear to be contagious.

The military experts said they will study the water and soil samples and confirm, possibly in ten days, if the condition was brought on by exposure to toxins.

Officials from the Ministry of Health visited Ba To, earlier this month, to gather skin and hair samples?they may have some test results next week.

On April 20, Deputy Health Minister Nguyen Thanh Long announced that his agency planned to seek help from the World Health Organization (WHO) and the US Center for Disease Control (USCDC).

Tarik Jasarevic, a spokesman for the WHO told Vietweek that the organization is monitoring the situation and awaiting further instruction.

?We are not aware of any reports of similar symptoms elsewhere in Vietnam? No evidence for human-to-human transmission of this disease has been presented,? he told Vietweek via email on Tuesday.

?The WHO is in contact with the Ministry of Health about this event and is ready to provide technical support if asked,? he added.

Jasarevic said WHO has yet to receive an official request from the Ministry of Health to provide assistance.

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

No shortage of suspects:

http://www.promedmail.org/mbds

Published Date: 2012-05-01 23:08:48
Subject: PRO/MBDS> Undiagnosed illness - Viet Nam (06): Quang Ngai, rickettsia
Archive Number: 20120501.0991

UNDIAGNOSED ILLNESS - VIET NAM (06): QUANG NGAI, RICKETTSIA SUSP.
REQUEST FOR INFORMATION
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A ProMED-mail post

http://www.promedmail.org

ProMED-mail is a program of the
International Society for Infectious Diseases

http://www.isid.org

Date: Wed 25 Apr 2012Source: Sai Gon Giai Phong Daily [edited]http://www.saigon-gpdaily.com.vn/Health/2012/4/100887/


"Rickettsia" virus identified as cause of bizarre skin disease
-----------------------------------------
The Ministry of Health has so far identified the "Rickettsia" virus as
cause of the bizarre skin disease that has afflicted residents in the
central province of Quang Ngai, said a health official on [24 Apr 2012].
Pham Hong Phuong, director of the Department of Health in Quang Ngai
Province, said that medical experts have initially identified the
Risketsia virus as cause of the baffling skin disease in Ba Dien Commune
in Ba To District.

Of 26 blood samples taken of patients, 14 tested positive for Rickettsia
virus, with 30 per cent of the samples showing small and fragile red
blood cells that could have caused death in patients.

Till [24 Apr 2012], Quang Ngai Province had reported 172 cases of the
skin disease infection, 8 of whom had died at medical clinics and 11
having died at home. The disease begins with a rash on the hands and
feet, and progresses to affect and damage the liver and subsequently
damages other body organs.

As the disease develops unpredictably, the province leaders have decided
to equip the General Hospital with a blood filtering machine for
reducing fatalities. In addition, the province will support 5 per cent
of the health insurance expenses of patients affected with this
mysterious skin disease and being treated at the Quy Hoa National
Leprosy Dermatology Hospital.

As scheduled, the ministry will send a mission team to the province on
[24 Apr 2012] to continue finding out the causes of the disease.

Meantime, another strange disease occurred in Son Ha District of Quang
Ngai Province. Many people are beginning to suffer bruises in feet,
hands and face without any clear cause. The disease has hospitalised 19
students so far. Medical workers in district centres examined and gave
drugs to the students, but the cause of the disease is yet unknown. As
of now, it is suspected to be a skin disease caused by contact with
chemical herbicides.

--
Communicated by:
PRO/MBDS
<promed-mbds@promedmail.org>

[This newswire mentions that a total of 172 people have been affected by
an undiagnosed illess in Quang Ngai. Among those, 19 people died of this
strange disease. The newswire also reports that Viet Nam Ministry of
Health identified Rickettsia as the pathological agent of the strange
disease in Quang Ngai.

Rickettsia is a genus of non-motile, Gram-negative, non-spore forming,
highly pleomorphic bacteria. The classification of Rickettsia into 3
groups (spotted fever, typhus and scrub typhus) was based on serology.
This grouping has since been confirmed by DNA sequencing. All 3 of these
contain human pathogens.

Rickettsia species are carried by many ticks, fleas and lice, and
transmitted to human during feeding or by scratching infectious feces
into the skin. Inhaling dust contaminated with dried infected lice or
flea feces may also cause infections.

Rickettsia causes diseases in humans such as typhus, rickettsialpox,
Boutonneuse fever, African tick bite fever, Rocky Mountain spotted
fever, Flinders Island spotted fever and Queensland tick typhus
(Australian Tick Typhus).

Several other tick-borne species of Rickettsia, including _Rickettsia
rickettsii_, broadly grouped under the heading "Spotted Fever Group
Rickettsia (SFGR)" have been shown to cause human infections. The
initial symptoms of tick-borne SFGR infections generally include fever,
headache, fatigue and muscle aches. A maculopapular or petechial rash
may be present, and frequently a distinctive eschar (blackened or
crusted skin) may develop at the site of a tick bite. Multiple eschars
may be present if more than one tick bite occurred, see more at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5504a1.htm and
http://wwwnc.cdc.gov/travel/yellowbo...rlichiosis.htm.

However, the article above does not say if a specific group of
Rickettsia is identified and how a differential diagnosis was made. In
addition, another cluster of skin disease was identified in 19 students
from Son Ha district of Quang Ngai province while the etiology remains
unclear.

Following comments are borrowed from bacterial disease moderator ML who
suggested other potential causes of this strange disease:


"At one point the lesions of the hands and feet are described as
"palmoplantar keratoderma", that is, an increased keratin layer on the
skin (hyperkeratosis) of the palms and soles; (see
http://emedicine.medscape.com/articl...rview#aw2aab6b).
Palmoplantar keratoderma may be inherited or acquired. Conditions that
can lead to acquired palmoplantar keratoderma include inflammatory and
reactive dermatoses such as Reiter's syndrome (arthritis, conjunctivitis
or uveitis, and urethritis that follow dysentery or chlamydial or
gonococcal genital infection) and infections, such as those due to human
papillomavirus, _Treponema pallidum_ (the bacterium that causes
syphilis), _Mycobacterium tuberculosis_, and _Mycobacterium leprae_.

"Encrusted scabies may progress to hyperkeratotic and/or crusted lesions
on palmar surfaces. Painful keratotic plaques that involved the skin
surrounding the ears, the nose, and the soles in association with
polyarthritis has been described in patients with HIV infection
(http://www.nejm.org/doi/full/10.1056...00312113492425) and
keratoderma of the palms and soles has been seen in glucan-treated
patients with AIDS (http://www.ncbi.nlm.nih.gov/pubmed/2953313).

"Arsenic exposure can lead to multiple, irregular, warty keratotic
lesions on the palms and soles, typically decades after chronic arsenic
ingestion. Exposure to certain chemicals, namely chloracnegens, has been
reported to present as palmoplantar keratoderma (Patel S, Zirwas M,
English JC. Acquired palmoplantar keratoderma. Am J Clin Dermatol. 2007;
8(1): 1-11; abstract available at
http://www.ncbi.nlm.nih.gov/pubmed/17298101). Chloracnegens are
halogenated aromatic compounds, such as chlorinated dioxins and
polychlorinated biphenyls (PCBs). Chloracne is an acne-like eruption of
blackheads, cysts, and pustules on the face and neck, associated with
overexposure to halogenated aromatic compounds, such as chlorinated dioxins.

"The news articles say that exposure to a herbicide is suspected as the
cause of this outbreak, as the patients were affected soon after
spraying herbicides in cassava fields. The most toxic dioxin,
2,3,7,8-tetrachlorodibenzo-p-dioxin, became well known as a contaminant
of Agent Orange, a herbicide used in the Viet Nam war. Dioxins were
incriminated to have poisoned president Viktor Yushchenko of Ukraine in
2004."

PRO/MBDS would appreciate further information from knowledgeable sources
regarding this undiagnosed illness in Quang Ngai province, Viet Nam.

For a map of Viet Nam with provinces, see
http://upload.wikimedia.org/wikipedi...ovincesMap.png.
For the interactive HealthMap/ProMED-mail map with direct links to other
outbreaks in Viet Nam and surrounding countries reported on ProMED-mail
and PRO/MBDS, see http://healthmap.org/r/008O. - Mod.QCN]

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

http://www.promedmail.org/

Published Date: 2012-05-02 21:34:27
Subject: PRO/EDR> Undiagnosed illness - Viet Nam (05): (QG) toxin susp. RFI
Archive Number: 20120502.1120880

UNDIAGNOSED ILLNESS - VIET NAM (05): (QUANG NGAI), TOXIN SUSPECTED, REQUEST FOR INFORMATION
************************************************** ******************************************
A ProMED-mail post

http://www.promedmail.org

ProMED-mail is a program of the
International Society for Infectious Diseases

http://www.isid.org

Date: Tue 1 May 2012
Source: VnnNews.net [edited]

http://www.vnnnews.net/rice-mold-added-to-list-of-suspects-in-vietnam-fatal-skin-condition

Villagers do not want to be disturbed while chasing away a ghost they believe is causing a skin condition that has killed at least 19 people.

Viet Nam health officers are adding rice mold to the list of suspects as they try to solve the mystery of a fatal skin condition in a district in the central region. At a Saturday [28 Apr 2012] meeting between the Health Ministry and authorities in Quang Ngai province, it was said that many of the patients in Ba To district had eaten rice covered with fungus, the Nguoi Lao Dong newspaper reported. Nguyen Thi Kim Tien, the health minister, said at the meeting that the ministry has ruled out microorganisms as the cause and narrowed the suspects to poisons transmitted through external contact or eating. She said the condition is not contagious.

The ministry is studying the moldy rice as well as other toxin suspects and will try to reach a final conclusion in the next 10 days. Otherwise, the ministry will seek help from the World Health Organization, Tien said.

The ministry's experts last week found the flea-carried _Rickettsia_ in half of the blood samples taken from the district on 12-13 Apr 2012 but then said the typhus bacterium did not cause the condition.

The skin condition begins with a high fever, loss of appetite and causes inflamed, thickened skin on the palms and feet. It has thus far claimed the lives of 19 people among 179 affected in the district, including 2 new cases on 28 Apr 2012, a man and a woman, both 35 years old.

Doctor Tran Hau Khang, director of the Viet Nam National Dermatology Hospital, said infected people, most of them children and young people, have their liver enzyme levels increase by 4-20 times the normal.

Le Han Phong, chairman of the district People's Committee, said the illness responds well to treatment, but patients who are not treated early can suffer liver problems and multi-organ failure.

The 1st infections in the district were reported last April [2011]. The condition died out by the year-end, but has returned, with 8 deaths between 27 Mar and 5 Apr this year [2012]. At least 29 people have been re-infected.

Last week, the Ministry of Defense collected soil, water, and air samples from the district to check whether toxins left from the Viet Nam war are causing the skin condition.

Meanwhile, many of the district's frightened residents have chosen to isolate themselves from outsiders, spooked by the visits of officials. Reu and Go Nghenh villages, home to the patients, are not allowing outsiders to visit because the residents want to be undisturbed as they "make offerings to drive away the ghost causing the disease," said Pham Van Vong, head of Go Nghenh village. Pham Van Dang, the head of Reu village, was reluctant to open the gate to health experts. "If they can get rid of the disease, they'd better do it. The more they came, the more people here have gotten sick. We are very scared now," Dang told the Nguoi Lao Dong newspaper.

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[The news article above concerns an outbreak in several villages in the Bo To district of Quang Ngai province, Viet Nam, on which ProMED-mail has previously reported. Those affected are reported to have developed an acute febrile illness with loss of appetite and respiratory symptoms followed by a rash on the hands and feet described as "palmoplantar keratoderma," (http://emedicine.medscape.com/articl...rview#aw2aab6b) accompanied by liver dysfunction and, in some patients, by multi-organ failure and death. Ulcers on the hands, feet, mouth, back, and abdomen, eye disease, stiffness of the limbs, and miscarriage are also described. Mainly children and young adults have been affected.

The disease is said to have started in April 2011, subsided somewhat between November 2011 and February 2012, and picked up pace again in March and April 2012. The numbers of patients affected vary in the news reports, but may be as high as a total of 150 in 2011 and a total of 179, with 27 deaths in 2012.

Early "treatment" is said to effective, but exactly what this treatment consists of has not been specified. However, some patients are said to relapse after an initial response to therapy.

Pictures of the rash on the hands and feet are available at http://www.saigon-gpdaily.com.vn/Health/2012/4/100698 and http://www.eyedrd.org/2012/04/breako...l-vietnam.html.

The diagnosis of a rickettsial etiology, initially said to have been made on the basis of a positive blood test in half of the blood samples, is now said to have been ruled out. The Weil-Felix test, which is inexpensive, easy to perform, and although 1st developed in 1916, still remains an important way to the diagnosis rickettsial diseases in resource-limited settings and was likely used in this outbreak. However, the Weil-Felix test lacks specificity and sensitivity. In any case, the clinical picture in this outbreak does not fit well with a rickettsial disease.

A better fit would be exposure to a toxin, and Vietnamese officials are now suspecting "molded rice" as well as other toxins as a cause of the outbreak.


Exposure to certain toxic chemicals, namely chloracnegens, has been reported to present as palmoplantar keratoderma (Patel S, Zirwas M, English JC. Acquired palmoplantar keratoderma. Am J Clin Dermatol. 2007; 8(1): 1-11; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17298101). Chloracnegens are halogenated aromatic compounds, such as chlorinated dioxins and polychlorinated biphenyls (PCBs). Chloracne is an acne-like eruption of blackheads, cysts, and pustules on the face and neck, associated with overexposure to halogenated aromatic compounds, such as chlorinated dioxins. The most toxic dioxin, 2,3,7,8-tetrachlorodibenzo-p-dioxin, became well known as a contaminant of Agent Orange, a herbicide used in the Viet Nam war. Dioxins were incriminated in the poisoning of president Viktor Yushchenko of Ukraine in 2004.

Quang Ngai is a Vietnamese province located in the South Central Coastal region along the South China Sea, 883 km (549 miles) south of Hanoi and 838 km (521 miles) north of Ho Chi Minh City (http://en.wikipedia.org/wiki/Quang_Ngai_province). The province has a large plain along the coast and in the center of the province and has mountains and hills in the west. Ba To is a rural district of Quang Ngai province with a population of 47 268 in 2003 (http://en.wikipedia.org/wiki/Ba_To_District).

A map of Viet Nam provinces can be seen at http://upload.wikimedia.org/wikipedi...ovincesMap.png. Viet Nam may also be found on the interactive HealthMap/ProMED-mail map at http://healthmap.org/r/2bxT. - Mod.ML]

[Ronan Kelly]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

Last update 04/05/2012 03:00:00 PM (GMT+7)

New strange skin disease appears in Quang Ngai
VietNamNet Bridge ? While the bizarre skin disease in Ba To district in the central province of Quang Ngai is still a mystery, a new skin disease has appeared in the province?s Son Ha district, affecting dozens of students.

According to local newspapers, tens of students in Son Ha district have contracted this disease, which caused their skin to turn dark.

Mr. Luong Ngoc Khue, chief of the Ministry of Health?s Medical Examination Agency, says that he heard the information from the local media and it has not been verified by relevant agencies.

Meanwhile, Dr. Tran Hau Khang, director of the Central Dermatology Hospital, says that he has examined some patients and found out that this is not an unknown disease, but a rare disease. The disease appears when patients contact with some substances that are sensitive to sunlight.

...

N.A

http://english.vietnamnet.vn/en/society/21940/new-strange-skin-disease-appears-in-quang-ngai.html

[Emily]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

The most toxic dioxin, 2,3,7,8-tetrachlorodibenzo-p-dioxin, became well known as a contaminant of Agent Orange, a herbicide used in the Viet Nam war.

http://www.ncbi.nlm.nih.gov/pubmed/11382178

J Occup Environ Med. 2001 May;43(5):435-43.
Recent dioxin contamination from Agent Orange in residents of a southern Vietnam city.
Schecter A, Dai LC, P?pke O, Prange J, Constable JD, Matsuda M, Thao VD, Piskac AL.
Source

Environmental Sciences Discipline, University of Texas School of Public Health at Dallas, TX, USA.
Abstract

Marked elevation of dioxin associated with the herbicide Agent Orange was recently found in 19 of 20 blood samples from persons living in Bien Hoa, a large city in southern Vietnam. This city is located near an air base that was used for Agent Orange spray missions between 1962 and 1970. A spill of Agent Orange occurred at this air base more than 30 years before blood samples were collected in 1999. Samples were collected, frozen, and sent to a World Health Organization--certified dioxin laboratory for congener-specific analysis as part of a Vietnam Red Cross project. Previous analyses of more than 2200 pooled blood samples collected in the 1990s identified Bien Hoa as one of several southern Vietnam areas with persons having elevated blood dioxin levels from exposure to Agent Orange. In sharp contrast to this study, our previous research showed decreasing tissue dioxin levels over time since 1970. Only the dioxin that contaminated Agent Orange, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), was elevated in the blood of 19 of 20 persons sampled from Bien Hoa. A comparison, pooled sample from 100 residents of Hanoi, where Agent Orange was not used, measured blood TCDD levels of 2 parts per trillion (ppt). TCDD levels of up to 271 ppt, a 135-fold increase, were found in Bien Hoa residents. TCDD contamination was also found in some nearby soil and sediment samples. Persons new to this region and children born after Agent Orange spraying ended also had elevated TCDD levels. This TCDD uptake was recent and occurred decades after spraying ended. We hypothesize that a major route of current and past exposures is from the movement of dioxin from soil into river sediment, then into fish, and from fish consumption into people.

http://dnr.wi.gov/environmentprotect...als/dioxin.htm

Dioxin/Furans

Previous And Current Sources: Dioxin does not have any commercial uses. It has been found in the environment, in the products and emissions of chemical plants manufacturing chlorinated phenols, and in the ash residues and emissions of municipal waste incinerators. Emissions may also occur from pulp and paper manufacturing plants, industrial accidents, combustion, and gasoline and diesel exhaust.

Health Effects: The EPA recently completed its review of the health literature on dioxin in the Dioxin Reassessment. The EPA currently considers dioxin to be a known human carcinogen based on limited evidence in humans. Studies on dioxin health effects in animals have also demonstrated possible developmental effects, reproductive effects such as endometriosis, and immunological effects such as thyroid problems (USEPA 2000). The most noted health effect in people who have been exposed to large amounts of the form 2.3.7.8-TCDD is chloracne a severe skin disease. Other symptoms include skin rashes, discoloration, and excessive body hair. There have also been reported changes in individual?s blood and urine that indicate liver damage. Exposure may also induce long-term alterations in glucose metabolism and subtle alterations in hormone levels. In animal studies, exposure has resulted in liver damage, kidney defects, reproductive problems and birth defects, weakened immune responses and disruption of the endocrine system (ATSDR 1999A).

Ecological Effects: Dioxins and furans are highly persistent and readily accumulate in animal tissue. Reported effects on fish include increased mortality, decreased growth, increased fin necrosis in addition to teratogenic effects. Dioxin has also been linked to increased mortality in birds as well as reproductive failures, decreased growth, hepatotoxic and carcinogenic effects (Eisler 1986).

[Emily]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI- unspecified rickettsia identified

Any reports on whether they have tested for heavy metals ?

Whilst arsenic can poison the liver, the description and pictures of the skin disease remind me of acrodynia, or pink disease, caused by inorganic mercury and primarily affecting children. Whilst you would normally expect mercury to cause kidney and neurological toxicity, there are conceivable circumstances under which it could preferentially hit the liver instead (i.e. if there were co-factors protecting kidneys and brain).

Welcome to the forum, SomeGuy. I hadn't heard about pink disease before. It sounds like they are testing for several toxins but maybe the range will expand, since now it looks like rickettsial etiology isn't strongly suspected.

Orientia tsutsugamushi

http://en.wikipedia.org/wiki/Scrub_typhus

http://wwwnc.cdc.gov/eid/article/12/7/05-0827_article.htm

http://wwwnc.cdc.gov/eid/article/12/2/pdfs/05-0967.pdf

[snip]

This outbreak affected
primarily children, and illness was characterized by fever
and severe abdominal distress (7).

Thank you, Anne, for finding out that scrub typhus could present as an outbreak in mostly children.

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

We have a report of a fairly simliar disease in a place called Achhro Thar, Pakistan in this thread (which also contains several other illnesses):

http://www.flutrackers.com/forum/showthread.php?t=135803

which was caused by fluoride poisoning. There are actually quite a few different toxins that could cause such an illness. This could just as easily be infectious in nature, perhaps vector-borne, especially in light of symptoms of high fever and hemorrhage, although it does not appear to be contagious. The inital outbreak in this thread remains completely undiagnosed, more than a year after it started.

Has anyone considered the possibility that the skin condition and the fatal condition resulting in multi-organ failure might be two different illnesses occurring in the same population? The Rickettsia does seem to be a very good match for the illness causing liver failure and hemorrhage, but not the thickening of the skin. Without knowing exactly which patients had which symptoms (did all the fatal cases have the rash?), it is impossible to tell if this is a possibility worth considering.

Nice to see the second outbreak is due to a rare, but known condition, and not a further variant of the unknown outbreak. Thank you, RoRo, for finding that article.

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

http://www.saigon-gpdaily.com.vn/Health/2012/5/101015/

HEALTH Friday, May 04, 2012, Posted at: 15:12(GMT+7)

Ba To District offers support to victims of bizarre skin disease
Authorities in Ba To District in the central province of Quang Ngai have provided free rice to people afflicted by the mysterious skin disease, said a senior official.



Le Han Phong, Chairman of the People?s Committee of Ba To District, said the district has provided 60 tonnes of rice to people suffering from the disease in some communes.

In addition, the district gave VND4.5 million (US$217) to each family of the dead and VND2.5 million to each family with a sick patient.

Vietnamese health officers are now suspecting rice mould as a possible cause of the mysterious and fatal skin condition in the central region, after patients in Ba To District said they had eaten rice covered with fungus.

Experts from the ministry said last week that ?Ricketsia, a virus transmitted by fleas, to be a cause, but blood samples of patients proved this was not the cause.

The skin disease begins with a high fever, loss of appetite and inflamed sort of rash on the hands and feet, and then progresses to affecting and damaging the liver and subsequently other body organs.

Quang Ngai Province had so far reported 180 cases of the skin disease, eight of whom died at medical clinics and 11 at home.

[SomeGuy]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI- unspecified rickettsia identified

Welcome to the forum, SomeGuy. I hadn't heard about pink disease before. It sounds like they are testing for several toxins but maybe the range will expand, since now it looks like rickettsial etiology isn't strongly suspected.

Thanks

Well acrodynia/pink disease is mostly historical though the odd case crops up. But when I first read the descriptions of the skin rash in this vietnam outbreak it was first thing I though off. (google some pictures - its looks similar to these vietnam pictures - some of them anyhow). Mercury would be a total random diagnosis here given that renal disease and neurological disease don't seem to be a major feature - but then one year in perhaps it is time for random diagnoses ?

One would think that if there is suspicion of toxins they would have screened for mercury and other metals amongst other things, but then they may discount mercury due to lack of kidney/neuro features.

There are so many stories coming out though and the language problems make it difficult to know exactly what is going on. Also - I'm wondering is there an official body in charge of the investigation and what are they saying ? I can't figure out if the stories we are reading are coming from official sources or through unofficial sources or journalists getting half the story.

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

I have to wonder whether this article was written by someone who read this thread first; I have not seen any other mention of the suspicion of arsenic:

http://vietnamnews.vnagency.com.vn/social-issues/224315/killer-disease-still-baffles-scientists.html

Killer disease still baffles scientists

QUANG NGAI — Authorities remain baffled by the mysterious skin disease that has killed nearly 20 people and infected many others in Quang Ngai Province though the Ministry of Health has sent two delegations to investigate.

Pham Hong Phuong, director of the Quang Ngai Province Department of Health, said the ministry has concluded it is palm dermatitis with liver problems. But he refused to provide further information about the ministry's conclusion or speculate about it.

But Dr Tran Hau Khang, director of the Ha Noi-based Central Dermatology Hospital, who led both delegations, rejected the conclusion.

He told the People's Army newspaper that it was based merely on symptoms and the cause remains unknown.

Blood tests found the presence of the rickettsia bacterium in 14 out of 26 patients in Ba To District. It is known to cause typhus among other diseases.

Viet Nam News called the office of the US's Center for Diseases Control in Ha Noi only to be told to seek information from the ministry. But Viet Nam News was unable to reach Minister of Health Nguyen Thi Kim Tien despite repeated efforts.

Experts speculate that it is not an infectious disease but is caused by arsenic.

The province has reported more than 176 cases since last year.

The province is assisting patients' families with VND5 million each. Ba To District has decided to distribute 60 tonnes of rice to locals in areas hit by a fatal skin disease that has been linked to the consumption of mouldy grain.

Le Han Phong, chairman of the local People's Committee said on Thursday that the rice would be divided amongst the people to replace the mouldy rice in their storerooms.

The Central Relief Fund donated VND1 billion (US$47,600) to the effort and the provincial Viet Nam Fatherland Front gave VND1 million ($48) to each household with an affected member. — VNS

[alert]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

Hat-tip Treyfish:

http://www.cimsi.org.vn/Default.aspx?action=News&newsId=30368

Issued disease treatment "strange" (05.05.2012) Print page

Ministry of Health leadership to visit disease patients, "stranger" the Health Ministry has sent several missions to find out the causes and cures the disease "strange".

From 19/04/2011 to present in the Ba Dien Commune, Ba Xa, Three Amazingly, Ba, Ba Ba Vinh district (Quang Ngai) with 176 appearance strange disease morbidity and mortality with 8 people symptoms: dermatitis, thick horns, desquamation, dryness, chapping of the hands, feet together with elevated liver enzymes (SGOT, SGPT). Under these circumstances the Health Ministry has sent several missions to find out the causes and cures the disease.

Based on clinical manifestations, histopathology images and results of treatment, initially identified this syndrome gastritis horn hands, feet, the cause is under investigation determined. On 05.04.2012, the Ministry of Health issued Decision No. 1454/QD-BYT issuing Guidelines Diagnosis and treatment of gastritis horn syndrome hands, the feet of patients.

[Ronan Kelly]

Re: Undiagnosed illness, 19 fatalities since April 2011 - Viet Nam: Quang Ngai, ProMED RFI

Monday, May 07, 2012, Posted at: 10:14(GMT+7)
Ministry issues new treatment plan for bizarre skin disease
The Ministry of Health in Vietnam has brought out a new method to treat the bizarre and mysterious skin disease that is affecting residents in the central province of Quang Ngai, along with issuing warnings of further complications.


Pham Van Trach, 16, suffering from the mysterious skin disease in Reu Hamlet in Quang Ngai Province (Photo: Tuoi Tre)
The new treatment method will replace the old plan that was issued in January 2012. From now on patients with mild inflictions can be treated by applying a cream containing corticoid and 2 per cent salicylic ointment all over their body, which will keep the skin moist and soft.

However, patients that are more seriously affected must be taken to the general hospital in the province or a bigger hospital in the city.
...

http://www.saigon-gpdaily.com.vn/Health/2012/5/101055/