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Multiple eschars do occur but are rare; multi- ple eschars should raise the suspicion of infection by Rickettsia aeschlimanii that is transmitted by Hyalomma spp cheap kamagra effervescent 100mg with visa. Comparable diseases are Siberian, or North Asian and Queensland tick typhus, Japanese spotted fever among others. With prompt recognition and treatment, death should be uncommon, yet 3 5% of cases reported in the United States in recent years have been fatal [14]. Risk factors for severe disease and death include delayed diagnosis and treatment and age above 40. In recent years infections by Rickettsia parkeri, transmitted by Amblyomma ticks were described from the United States and South American countries. Scrub typhus Scrub typhus is endemic in rural South and Southeastern Asia and the Western Pacic. Man is infected by the bite of larval trombiculid mites (chiggers) that typically bite humans on the lower extremities or in the genital region. With continued global warming, the fungus Geomyces destruc- tans has decimated fruit bat populations worldwide; as a result more mosquitoes and mosquito-borne viral illnesses can be expected to sur- face. Viral skin diseases vary in their clinical manifestation, geographic Imported Skin Diseases, Second Edition. Here we have reviewed the most prominent viral infections with specic attention to their accompanying cutaneous manifestations, diagnosis, and treatment. Chikungunya virus Epidemiology In 2005 and 2006 there were two major outbreaks of the chikungunya virus in India and Reunion (an island in the Indian Ocean). Subsequently the transmission of the disease has occurred in separate waves to virtu- ally all continents, including North America (United States) and Europe (France and Italy). In 2007, chikungunya fever was transmitted to Italy for the rst time, presumably from an Indian man visiting relatives. This arthropod-borne virus often presents with the triad of fever, arthralgia, and rash. In most cases, resolution of symptoms occurs 10 13 days after initial exposure; however, myalgia and arthralgia can persist for up to 1 year [2]. Elimination of breed- ing sites via insecticides and use of mosquito nets are effective prevention modalities. In 2009, the rst case in 75 years was reported in Florida with a subsequent 65 cases conrmed in 2010. Over 21,000 cases have been reported in Puerto Rico, making it the largest outbreak in history [3]. Infection with one strain can only produce lifelong immunity to that par- ticular strain. Dengue is commonly called break-bone fever because of the associated debilitating joint and muscle pain. Currently, there is no vaccine available but progress on a tetravalent vaccine, which will include four different strains of the virus, is being made [2]. The use of insecticides and adequate solid waste disposal are effective means of prevention. The virus most likely orig- inated in Africa and has had repeated outbreaks in the Americas until the twentieth century. Despite introduction of the vaccine in the twen- tieth century, the disease was imported by a Belgian traveler returning from Gambia in 2001, and from Suriname to the Netherlands in 2000 [1]. Clinical features The disease initially manifests as a nonspecic febrile illness that usually remits a week after exposure. Diagnosis In early disease, viral culture is the preferred method of diagnosis, but serology (IgM or fourfold rise in IgG) can also be used [2]. Immunization with the live attenu- ated vaccine is recommended 7 10 days before travel to endemic regions; boosters are required every 10 years [2]. In 1999, a strain of West Nile virus prevalent in Israel was imported into New York City, and since then the virus has spread across the United States becoming endemic [1]. It is now the most common cause of epidemic meningoencephalitis in North America [1]. Clinical features Approximately 80% of patients infected with West Nile virus are asymp- tomatic [2]. Of the remainder, most develop West Nile fever, a nonspecic febrile syndrome, which can include a macular rash on the trunk that may desquamate. Neurologic involvement is more common in the elderly and the immunosuppressed [2]. Treatment The disease is self-limited and treatment of neurologic disease is support- ive. Without a current vaccine, prevention is key, directed at avoiding mosquitoes [2]. Hemorrhagic fevers Ebola and Marburg Epidemiology Ebola and Marburg viruses comprise the Filoviridae family and cause deadly and virtually identical hemorrhagic disease. An isolated case of Ebola occurred via an accidental needlestick in 1976 in a United Kingdom laboratory processing material from patients in Africa.

Several studies have shown there is a high frequency of balding in the fathers of bald men cheap 100mg kamagra effervescent overnight delivery. So far, attempts to identify the relevant genes have been limited to a small number of candidate gene studies. No associations have been found with 5-reductase genes (27,30) or the insulin gene (31). This nding therefore conrms there is a mater- nal inuence on male balding but does not explain the genetic contribution from the father. Prevalence Population frequency and severity of androgenetic alopecia in both sexes increase with age. Almost all Caucasian men develop some recession of the frontal hairline at the temples during their teens. Deep frontal recession and/or vertex balding may also start shortly after puberty although in most men the onset is later. A small proportion of men (15 20%) do not show balding, apart from post-puber- tal temporal recession, even in old age. Some authorities have suggested that scalp hair loss in elderly men may develop independently of androgens (senescent alopecia) but this remains to be veried (35). Balding is less common in Asian men although there is quite a wide variation in pub- lished frequencies. Two recent studies from Thailand and Singapore found prevalence rates not far short of those in Caucasian men (36,37). In Korean men the frequency is 20 40% lower than in Caucasian men in the 40 70 age group although the difference becomes less pro- nounced with advancing age (39). Preservation of the frontal hairline was a common feature in the series reported from Korea and 11. One early study reported that balding is four times less common in African- American men than in Caucasians (40). The frequency and severity of androgenetic alopecia is lower in women than in men but it still affects a sizeable proportion of the population. Two studies in Caucasian women in the United Kingdom and the United States reported prevalence rates of 3 6% in women aged under 30, increasing to 29 42% in women aged 70 and over (41,42). As in men, androgenetic alopecia is less common and appears to start later in life in Asian women, although nearly 25% of Korean women over 70 years of age show evidence of hair loss (39). There are no published data on the prevalence of androgenetic alopecia in African women although clinical experience suggests that its frequency is similar to that in other racial groups. Under normal circumstances it has no adverse effect on physical well-being apart from increasing the risk of chronic photodamage to unpro- tected scalp skin. Under exceptional conditions a full head of hair may also contribute to ther- moregulation. The French military surgeon Dominique-Jean Larrey observed that the bald men (and men without hats) were the rst to die during the Russian campaign in the winter of 1812. Yet balding still has a powerful effect on the human psyche, to the extent that few men would choose to go bald were the choice available. However, for some men balding is important enough for them to seek treatment and, for a few, concern about hair loss reaches the level of a body dysmorphic disorder. Men in the latter group are important to recognize as treatment aimed at addressing the perceived hair problem is unlikely to be successful. A number of studies have shown that male balding has an adverse effect on quality of life (though this is almost inevitable in those seeking professional advice) (43). Nevertheless, balding is often seen as a trivial issue (mainly by non-sufferers) which may make men reluctant to approach their physician as they perceive, rightly or wrongly, that they will not receive a sympathetic response. In contrast to the pre- vailing attitude to male balding, however, society generally regards it as abnormal for women to lose their hair. Consequently the adverse effect of balding on quality of life tends be more severe in women than in men. In quality-of-life studies, individual responses were more related to self-percep- tion of hair loss than to objective or clinical ratings and those women most distressed by hair loss were more poorly adjusted and had a greater investment in their appearance (44,45). The physician needs to be alert and sensitive to these issues and needs counseling and psychothera- peutic skills that go beyond merely prescribing treatment. Diagnosis The diagnosis of androgenetic alopecia in men rarely causes difculties. In cases presenting with general thinning, other causes of diffuse hair loss should be considered, particularly when the hair loss progresses quickly. This situation is perhaps most likely to be seen in teenage boys brought along by worried parents. The diagnosis of female androgenetic alopecia may be more challenging although it can usually be made on clinical grounds.