Baffling viral and protozoal infections

Our lot is a perilous age ... but where shall we fly to escape from pestilences that come and pestilences that do not come, from ships that bring us yellow fever, from cattle diseases that can only be exterminated by exterminating the cattle, from infectious patients whose pulses must be felt with a pair of tongs and their chests explored with tarred stethoscopes.

Jacob Bigelow 1860

Almost any infection, especially if subacute or insidious in its onset, can be baffling and can belong to the 'fever of undetermined origin' group of infections. Syphilis and tuberculosis were the great mimics of the past. Now malaria and Epstein-Barr mononucleosis can be regarded as important mimics. Epstein-Barr mononucleosis (syn: infectious mononucleosis, glandular fever) can be a perennial baffler and can be confused with HIV infection in its primary clinical phase. Any of the febrile diseases can be confusing before declaring themselves with classical symptoms such as the jaundice of hepatitis or the rash of dengue fever, or before serological tests become positive. Viral and protozoal infections that can present as masquerades include:

• HIV infection (especially primary)

• Epstein-Barr mononucleosis (EBM)

• TORCH organisms o toxoplasmosis o rubella o cytomegalovirus (CMV) o herpes simplex virus

• Mosquito-borne infections o malaria o dengue fever o yellow fever o Japanese encephalitis o Ross River fever

The TORCH organisms (TORCH being an acronym for toxoplasmosis, rubella, cytomegalovirus and herpes) are well known for their adverse intrauterine effects on the foetus. Three are viral (toxoplasmosis is a Protozoa) and the first three of these foetal pathogens are acquired by passage across the placenta. Most of these organisms are noted for being opportunistic infections in immunocompromised patients, especially in later stage HIV infection.

The mosquito-borne infections are mainly viral, apart from the Protozoa causing malaria, and are of particular significance in travellers returning from endemic areas.

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