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Fever in a returned traveller
Ouli XieIntern
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Fever in a returned traveller
• 30 year old man presents with fever 38.5C associated with abdominal pain– Returned 2 months ago from a 3 week trip to India– Multiple exposures and no travel prophylaxis– Associated with 2 days of loose bowels but now
BNO for 2 days– Some nausea but no vomiting
• PHx: Nil• Meds: Nil
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Examination
• Haemodynamically stable, T 38.5C• Diaphoretic, unwell looking• Fluid depleted• Dual heart sounds, no murmur• Chest clear to auscultation• Tender RIF on palpation, but abdomen soft
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DDx?
• Malaria• Bacterial enteritis• Inflammatory bowel disease
• Appendicitis!
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An approach
• History• Travel/exposure history• Examination• Common causes of fever• Causes not to miss• Investigations• Treatment
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History
• Time course is essential– Including progression of illness
• Incubation period can help distinguish illnesses– Dengue unlikely after 2 weeks
• Associated features– Rash, headache, GI symptoms,
myalgia/arthralgia etc.
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Exposure history
– travel – specific places and dates rural/urban
– occupation– activities – detailed list of activities animals, fresh water, food etc.– drugs – including IVDU– sex
• T
• O• A
• D• S
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Causes
• Travel specific– Malaria– Dengue– Bacterial enteritis
• More prevalent in area of travel– Influenza– Respiratory illnesses
• General causes of fever– Appendicitis etc.
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The big 3
• Malaria
• Typhoid
• Dengue
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Malaria
• Caused by mosquito-borne protozoan– Plasmodium falciparum– Plasmodium ovale– Plasmodium vivax– Plasmodium malariae– Plasmodium knowlesi
• Carried by dawn/dusk biting Anopheles mosquito
• Multiple stages in life cycle
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Malaria life cycle
http://www.cdc.gov/malaria/about/biology/
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Characteristic features
• Falciparum malaria can be fulminant and cause death
• Ovale and vivax have dormant liver stages and may reactivate
• Malariae may have low levels of parasetaemia and recrudesce weeks after infection
• Characteristically described as cyclical fevers
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Falciparum malaria
• The most common cause of symptomatic malaria
• Risk of complicated malaria– Systemic symptoms or high level of parasetaemia
>5%• Incubation 12-14 days• Associated with high levels of chloroquine
resistance
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Complicated malaria
• Systemic symptoms or high parasetaemia– Altered conscious state +/- seizures– ARDS– Circulatory collapse– Metabolic acidosis– Renal failure or haemaglobinuria– Haptic failure– Coagulopathy +/- DIC– Severe anaemia– Hypoglycaemia
http://courses.washington.edu/med620/mechanicalventilation/case3answers.html
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Clinical features
• Hx– High cyclical fevers– May have non-specific
associated features including:• Headache, cough,
nausea/vomiting, diarrhoea, abdo pain, myalgias/arthralgias
• Examination– Splenomegaly– Jaundice
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Diagnosis
• Thick and thin films– Operator dependent– Serial films required
• Rapid diagnostic tests– ICT used at RMH
(immunochromatographic test)– Used to detect malaria antigens– Can distinguish between Falciparum
and non-falciparum malaria– Sensitivity and specificities ~95%
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Treatment
• Artesunate is the preference for treatment of falciparum malaria– 3 day course of artemether-lumefantrine– IV form available for severe falciparum malaria
• Always given in combination to prevent resistance• Non-faciparum malaria can be treated with
chloroquine if sensitive– Note primaquine required for liver stage of vivax and
ovale
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Dengue
• 4 serotypes• Carried by day-biting mosquito Aedes aegypti• Usually not lethal• Risk of dengue haemorrhagic fever– Infection with 1 serotype results in super-antigen
response– Circulatory collapse and
haemorrhage/coagulopathy
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Dengue clinical features
• History– Fever, arthalgias, myalgias and
severe headache (often retro-orbital)– “Breakbone fever”– Maculopapular rash
• Examination – Non-specific– May find some lymphadenopathy,
rash, hepatomegaly
http://en.wikipedia.org/wiki/Dengue_fever
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Diagnosis and treatment
• Basic bloods– Classically shows a thrombocytopaenia and
leukopaenia• Diagnosis– Dengue serology– Dengue PCR/ELISA
• Treatment– Supportive
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Enteric fever
• Typhoid/paratyphoid fever• Caused Salmonella enterica serotype Typhi or
serotype paratyphi• Faecal-oral spread• Typhoid Mary– Can be associated with chronic carriage– Colonisation of biliary system
• Incubation 5-21 days
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Clinical features
• Hx– Classic progression described
• Rising fever in first week• Abdo pain in second week with
appearance of rash• Septic shock in third week
– May describe constipation or diarrhoea
• Exam– Characteristic rose spot rash– Abdo pain, hepatosplenomegaly
http://www.zipheal.com/typhoid/typhoid-fever-symptoms/3761
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Investigations
• Basic investigations– May demonstrate a leukocytosis or leukopaenia– Abnormal LFTs even in hepatitic pattern
• Diagnosis– Blood culture (+ve in 40-80%)– May also be cultured in stool or urine– Serology minimal value
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Treatment
• Supportive treatment• Antibiotic therapy– Azithromycin or ceftriaxone– Ciprofloxacin useful if susceptible– Beware resistance against fluoroquinolones in
South/South-East Asia
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Summary
• Take a careful history• Remember that fever in returned traveler
does not have to be a travel related illness!• Remember the big 3 – malaria, dengue and
enteric fever• Time course can often be the key
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References
• Uptodate• Yung, Allen P (2005). Infectious diseases : a
clinical approach (2nd ed). IP Communications, East Hawthorn, Vic
• Kumar P and Clark M (Eds) (2009) Kumar and Clark’s Clinical Medicine (7th edition). Edinburgh: Saunders Elsevier.