Neurology

November 2016

Up front

Letters to the editor

Volume 45, No.11, November 2016 Pages 778-780

The opinions expressed by correspondents in this column are in no way endorsed by the Editors or The Royal Australian College of General Practitioners.

Vetran's health

The assertion that veterans have different medical issues to civilians (AFP March 2016)1 is inconsistent with my experience. Unfortunately, this belief is held by many veterans who avoid consulting non-military doctors for conditions they associate with military service. They express the view that doctors who have not experienced war are unable to treat them appropriately. This is most evident with post-traumatic stress disorder (PTSD).

Civilian and military individuals (those with the genetic predisposition) may develop PTSD after emotional and/or physical trauma. There is no clinical difference in their presentations and both groups respond similarly to appropriate therapy. However, veterans are more likely to be diagnosed because practitioners are on alert to this condition in this patient population group.

I believe PTSD is overlooked in some civilian anxiety presentations, which will therefore skew prevalence data, leading to the impression that veterans are different to other patients.

Henry Berenson MBBS, Canberra, ACT

Reference

  1. Reed RL, Masters S, Roeger LS. The Australian Defence Force Post‑discharge GP Health Assessment. Aust Fam Physician 2016;45(3):94−97. Available at www.racgp.org.au/download/Documents/AFP/2016/March/201603Reed.pdf [Accessed 15 September 2016].

Reply

We thank Dr Berenson for his observations on the recent series of papers relating to veterans’ health. This series of articles was written to inform general practitioners (GPs) of the health problems some veterans develop and how to best negotiate the Department of Veterans’ Affairs treatment pathways. In any one year, fewer than 60 GPs will enter the Australian Defence Force (ADF) as full-time or reserve medical officers. It is not possible for this relatively small number of ex-ADF GPs to meet the needs of all veterans. The mental health conditions experienced by veterans are often problems commonly seen by GPs, although the contributing factors can sometimes be military-specific. The essential component for the treatment for most of these conditions is a therapeutic relationship with a GP. We believe establishing a good relationship with general practice (and consulting with non-military doctors) is a critical element in many veterans’ successful transition into civilian life.

There is good evidence from Australian and international studies that military service can be associated with exposure to specific occupational hazards. As a result, the veteran population can sometimes be at greater risk of specific types of health problems than their civilian counterparts. For example, high-impact noise from weapons, vehicles and aircraft can result in acoustic injury, and hearing loss and tinnitus are common among serving and former serving ADF members.

As Dr Berenson notes, civilians and military individuals can develop post-traumatic stress disorder (PTSD). Epidemiological studies in Australia suggest overall higher rates of PTSD in the veteran community, particularly for Vietnam veterans exposed to combat.1,2 However, the veteran population is very heterogeneous and there is uncertainty with respect to PTSD rates across different veteran cohorts. The Department of Defence and the Department of Veterans’ Affairs have launched the Transition and Wellbeing Research Programme, which will investigate the prevalence of mental health disorders among contemporary veterans. This will include PTSD.

We agree with Dr Berenson that PTSD might sometimes be overlooked in individuals presenting with anxiety. Prior to 2013, PTSD was categorised in the Diagnostic and statistical manual of mental disorders (DSM) with anxiety disorders. In DSM-5, PTSD was moved into a separate chapter called ‘Trauma- and stress-related disorders’.3 This change may help to improve diagnostic accuracy.

A frequent finding in the PTSD efficacy literature is that high numbers of veterans who begin treatment eventually drop out. As a result of this, and the fact that some veterans are often reluctant to seek treatment in the first place, it may lead to fewer veterans with PTSD being effectively treated. We suspect Dr Berenson is right that one reason is that some veterans may believe that only doctors who have experienced war can treat them. Being better informed about veterans’ health issues is probably one the best ways a GP can build the therapeutic alliance with veterans, resulting in more effective healthcare.

Richard L Reed MD, FRACGP, Head, Discipline of General Practice, Flinders University, Bedford Park, Adelaide, SA
Gerard F Gill RFD, PhD, FRACGP, FARGP, Professor, Alfred Felton Chair in General Practice in Rural and Regional Victoria, Deakin University, School of Medicine, Geelong, Vic; veteran and the Secretary of the RACGP Chapter of Military Medicine; past member of the national DVA LMO Committee
Alexander McFarlane AO, MBBS (Hons), MD, FRANZCP, Dip Psychotherapy, Director of the Centre for Traumatic Stress Studies, University of Adelaide, SA; and Psychiatric Advisor, Department of Veterans’ Affairs, Canberra, ACT


Treatment for tonsillitis

The patient in the case study by Madanelo et al (AFP August 2016)1 was a teenager aged 16 years who was treated with amoxicillin for tonsillitis. The Therapeutic Guidelines for the treatment of group A streptococcal infection is penicillin.2 I remind AFP readers and the authors of the case study that tonsillitis in a teenager is often a first presentation of Epstein–Barr infection (infectious mononucleosis or glandular fever). The presumptive use of amoxicillin in this setting can produce a dramatic, widespread and impressive rash (Figure 1).

Stuart Garrow MBBS, DRCOG, MPH, FRACGP, General Practitioner, Parkdale, Vic

References

  1. Marmar CR, Schlenger W, Henn-Haase C, et al. Course of posttraumatic stress disorder 40 years after the Vietnam War: Findings from the National Vietnam Veterans Longitudinal Study. JAMA Psychiatry 2015;72(9):875–81.
  2. O’Toole BI, Catts SV, Outram S, Pierse KR, Cockburn J. The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder. Am J Epidemiol 2009;170(3):318–30.
  3. Cooper J, Metcalf O, Phelps A. PTSD – An update for general practitioners. Aust Fam Physician 2014;43(11):754–57.


Treatment for tonsillitis

The patient in the case study by Madanelo et al (AFP August 2016)1 was a teenager aged 16 years who was treated with amoxicillin for tonsillitis. The Therapeutic Guidelines for the treatment of group A streptococcal infection is penicillin.2 I remind AFP readers and the authors of the case study that tonsillitis in a teenager is often a first presentation of Epstein–Barr infection (infectious mononucleosis or glandular fever). The presumptive use of amoxicillin in this setting can produce a dramatic, widespread and impressive rash (Figure 1).

Stuart Garrow MBBS, DRCOG, MPH, FRACGP, General Practitioner, Parkdale, Vic

References

  1. Madanelo S, Baptista A, Ribeiro J, Moaris P. Widespread rash after throat infection. Aust Fam Physician 2016;45(8):579–80. Available at www.racgp.org.au/afp/2016/august/widespread-rash-after-throat-infection [Accessed 15 September 2016].
  2. Therapeutic Guidelines. Acute pharyngitis and/or tonsillitis. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited, 2014. Available at https://tgldcdp.tg.org.au/viewTopic?topicfile=ear-nose-throat-infections&guidelineName=Antibiotic#toc_d1e47 [Accessed 15 August 2016].

Reply

We thank Dr Garrow for his comments and for raising important topics in our original article1 for discussion. In reality, it is true that tonsillitis can be the first presentation of Epstein–Barr virus (EBV) infection in a teenager. However, in this case, the clinical presentation (fever, sore throat, localised cervical adenopathy, tonsillar hyperemia and hypertrophy with exudate, and no hepato/splenomegaly in a patient with a good general state and no systemic manifestations), a positive result for group A ß-haemolytic streptococcus (GAS) in rapid antigen detection test, and adequate clinical response to antibiotics favour streptococcal tonsillitis.

In respect to treatment, we agree that penicillin is the first-line treatment for acute streptococcal tonsillitis in countries such as Australia and the US;2 however, in Portugal, penicillin is available only in the intramuscular form; oral penicillin is not available. In our country, the clinical practice guidelines are developed by the Directorate-General of Health (DGS), a public body of the Health Ministry. According to DGS recommendations, the first-line treatment for streptococcal tonsillitis is oral amoxicillin because of its effectiveness, good safety profile and low cost.3

Intramuscular penicillin G benzathine has the disadvantage of uncomfortable administration, which is why it should only be used when oral administration of amoxicillin is not possible, or adherence to complete treatment is not guaranteed.3 Furthermore, the last national data in Portugal showed that antimicrobial resistance in GAS was 0% to amoxicillin/penicillin (10% to erythromycin and 7% to clindamycin).4

A rash induced by amoxicillin can occur in acute EBV infectious mononucleosis, so a good differential diagnosis is important. Curiously, a recent study has shown a much lower incidence of this rash than previously reported (about 30% versus 80–100%).5 Amoxicillin rash in EBV infection is usually an extensive and severe maculopapular or morbilliform eruption involving the face, neck, trunk, limbs, palms and soles (as shown in the image presented by Dr Garrow). In our patient, the classic pattern of guttate psoriasis was evident, consisting of multiple, salmon-pink to erythematous, round-to-oval papules with a fine silvery scale, associated with mild pruritus but sparing the face, palms and soles. This clinical scenario, the history of previous streptococcal tonsillitis and the excellent response to treatment support the diagnosis of guttate psoriasis.

We appreciate and thank Dr Garrow for his comments, which provide discussion and clarification of the theme. We hope to have given a useful for explanation of the same.

Sofia Madanelo, Family Medicine Trainee, Unidade de Saúde Familiar (USF) Santa Joana, Aveiro, Portugal
Ana Baptista, Family Medicine Trainee, USF Viseu- Cidade, Viseu, Portugal
Joana Ribeiro, Family Medicine Trainee, USF Aveiro-Aradas, Aveiro, Portugal
Paulo Morais, Consultant Dermatologist, Department of Dermatovenereology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal

Reference

  1. Madanelo S, Baptista A, Ribeiro J, Moaris P. Widespread rash after throat infection. Aust Fam Physician 2016;45(8):579–80. Available at www.racgp.org.au/afp/2016/august/widespread-rash-after-throat-infection [Accessed 15 September 2016].
  2. American Academy of Pediatrics – Committee on Infectious Diseases. Red book: Report of the Committee on Infectious Diseases. 29th edn. Elk Grove Village, IL: American Academy of Pediatrics, 2012.
  3. Diagnóstico e Tratamento da Amigdalite Aguda na Idade Pediátrica. Norma nº 020/2012 da Direcção-Geral da Saúde. Lisboa, Portugal: Direcção-Geral da Saúde, 2012. Available at www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0202012-de-26122012.aspx [Accessed 28 August 2016].
  4. Melo-Cristino J, Santos L, Silva-Costa C, et al. The Viriato study: Update on antimicrobial resistance of microbial pathogens responsible for community-acquired respiratory tract infections in Portugal. Paediatr Drugs 2010;12(Suppl 1):11–17.
  5. Chovel-Sella A, Ben Tov A, Lahav E, et al. Incidence of rash after amoxicillin treatment in children with infectious mononucleosis. Pediatrics 2013;131(5):e1424–27. 

Correspondence afp@racgp.org.au

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Letters to the editor