Subject: PRO/EDR> Undiagnosed illness - Viet Nam: (QG) fatal, palmoplantar hyperkeratosis, resurg.
Archive Number: 20180113.5556991
UNDIAGNOSED ILLNESS - VIET NAM (01): (QUANG NGAI) FATAL, PALMOPLANTAR HYPERKERATOSIS, RESURGENCE
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Date: Thu 11 Jan 2018
Source: Vietnamnet [edited]
Mysterious skin disease kills one in Quang Ngai. A strange skin disease has claimed the life of a student in Ba To District, central province of Quang Ngai, according to the provincial Health Department. Nguyen Tan Duc, the department's director, on [Tue 9 Jan 2018] confirmed the death of the 13-year-old student from Ba Ngac Secondary School in Ba Ngac Commune.
The health centre in Ba To District came across the student earlier this year [2018]. He was believed to be suffering from an unidentified skin disease, but was later diagnosed with dermatitis, a condition that causes people's skin to peel off their feet and palms.
He also showed symptoms of high liver enzyme and septicemia (a blood infection), and was admitted to Da Nang General Hospital for treatment. However, he died after a week.
A total of 10 cases have been reported from the end of 2017 [to today]. The 1st case was reported in 2011; since then, 26 deaths have been reported, according to the Vietnam Television (VTV). Tran Dac Phu, head of the Ministry of Health's Preventive Medicine Department, said that the disease was more common in the age group between 15 and 29.
Earlier, after gathering evidence and consulting experts, the ministry concluded the disease was caused by mold, mainly aflatoxins, and by eating old rice, he said. Aflatoxins are poisonous carcinogens that are produced by certain molds
(Aspergillus flavus and Aspergillus parasiticus), which grow in soil, decaying vegetation, hay and grains. The ministry has recommended to people not to eat old rice, to clean the environment and their bodies.
"The patient, who is confirmed to be suffering from this disease, must be treated according to the method defined by the ministry," Phu said.
Currently, the health sector is conducting disinfection in the area where the disease has resurfaced and is continuously working towards finding its cause.
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[The news article above refers to an outbreak mainly in the Bo To district of Quang Ngai province, Viet Nam. Those affected were reported to have developed an acute febrile illness with loss of appetite and respiratory symptoms followed by a rash on the hands and feet, with liver dysfunction, and in some patients multiorgan failure and death. Ulcers on the hands, feet, mouths, back, and abdomen, eye disease, stiffness of the limbs, and miscarriage were also described. The disease was said to affect mainly children and young adults. The disease was said to have started in April 2011, subsided somewhat between November 2011 and February 2012, and picked up pace again in the spring of 2012, 2013, and 2014; it was noted to recur after resumption of eating moldy rice. The numbers of patients affected and the death toll have varied in the news reports.
Pictures of the rash on the hands and feet are available at http://english.vietnamnet.vn/fms/soc...y-disease.html and http://english.vietnamnet.vn/fms/soc...uang-ngai.html.
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 (https://www.ncbi.nlm.nih.gov/pubmed/17298101). Conditions that can lead to acquired palmoplantar keratoderma include inflammatory and reactive dermatoses such as reactive arthritis (arthritis, conjunctivitis or uveitis, and urethritis that follow dysentery or chlamydial or gonococcal genital infection). 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 (https://www.ncbi.nlm.nih.gov/pubmed/2953313). The authors postulated that "since glucan is a naturally occurring component of the cell walls of yeast, fungus, and some bacterial organisms, recognition of its ability to induce such a striking reaction pattern may be of general significance."
Arsenic exposure can also 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 https://www.ncbi.nlm.nih.gov/pubmed/17298101). Dioxins are also associated with hyperkeratosis, the most toxic of which, dioxin, 2,3,7,8-tetrachlorodibenzo-p-dioxin, is a contaminant of Agent Orange, a herbicide used in the Viet Nam war. However, a WHO report in 2012 (entitled "Media statement on Inflammatory Palmoplantar Hyperkeratosis (IPPH) syndrome in Ba To district, Quang Ngai Province" http://www.wpro.who.int/vietnam/medi...28June2012/en/) said that there was no evidence of elevated levels of heavy metals or agrochemicals in human or environmental samples.
The population of the Ba To district is predominantly the Hre ethnic group (http://en.wikipedia.org/wiki/H're_people), which may have a genetic predisposition to palmoplantar keratoderma.
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 showing the location of Ba TO can be found at https://www.google.com/maps/place/Ba...Ngai,+Vietnam/. 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]
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