fever in the returning traveller part ii dr viviana elliott consultant acute medicine
TRANSCRIPT
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Fever in the returning traveller Part II
Dr Viviana Elliott
Consultant Acute Medicine
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Viral haemorrhagic Fever
Lassa fever RARE!!!
Only VHF reported inUK
Dengue
Others Ebola
Marburg
Yellow fever
Malaria: Plasmodium falciparum
5000 x common than Lassa fever!!!!!
Fever, rural area, likely contact, high fever ,
severe exudative sore throat, prostration out
of proportion with fever
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Malaria• Should be thought in febrile illness in travellers
returning to Europe from tropic
Sub - Saharan Africa
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Malaria
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Early diagnosis and assessment of severity is vital to avoid deathsSymptoms are non specific
Almost 50% are a febrile on presentation but all have history of fever
Consider country of travel, stopovers and date of return. Incubation: at least 6 days and within 3 months more with prophylaxis
Consider other infections: Typhoid fever, hepatitis, dengue fever, avian influenza, SARS, HIV, Meningitis, Encephalittis and VHF
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Urgent investigations
• Thick (find it) and thin (typify it) and rapid antigen test ( less sensitive for non falciparum, no info about parasite count, maturity or mixed species. Use in adjunct with microscopy)
• FBC: Thrombocytopenia, U&Es, LFT and
GLUCOSE
• BCM for typhoid and other bacteriemia
• Urine dipstick for haemoglobinuria and culture. Stool culture if diarrhoea
• CXR to r/o CAP
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La
Laboratory diagnostic approach Diagnostic Approach
↑WBC with neutrophils ↓ WBC with neutrophils ↓ WBC with lymphocytes
Pneumonia UTILeptospirosisBrucella
TyphoidOther Salmonella
ViralRickettsial
FBC
Eosinophils: helminth, drugs. Unlikely bacterial
Very High High bili + Mod trans + Renal disfunction
Viral hepatitis Yellow feverToxin
Leptospirosis
LFTs
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Falciparum Malaria or mixed infection
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Admit all cases and assess severity
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Complicated Malaria
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Treatment
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Enteric Fever(Typhoid and Paratyphoid))
• Commonest serious tropical disease from Asia
• Distribution: worldwide in developing countries
• Asia and south east Asia
>100 cases per 100.000 person per year
77% in person visiting friends and family
• Most cases occur 7 – 18 days after exposure
range 3-60 days
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Clinical Presentation of Enteric Fever
Fever is almost invariable Relative bradycardia only first week
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Clinical presentation of Enteric Fever
• Constipation more common than diarrhoea
initial loose stools fairly common
• Maybe evanescent rash: “Rose spots”
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InvestigationsFirst Week:
Bloods: low WBC, platelets and mildly raised LFTs
BCM positive 40-80%
• Second week
Urine culture 0-58%
Stool culture 35-65%
Bone marrow higher sensitivity than BCM
• Newer rapid serology IgM against specific S Typhi
• Widal test lacks sensitivity and specificity Not recommended
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Complications
• Incidence: 10-15%
illness >2 weeks
• GI Bleed
• Intestinal perforation
• Typhoid encephalopathy
Vaccination provides incomplete protection
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Treatment• Unstable treat empirically pending BCM
• First choice: Ceftriaxone 2g iv
• 70% of isolated S typhi and paratyphi imported into Uk are resistant to Cipro
• In patients returning from Africa resistance 4%
• If resistance to Cipro, Azitromycin
• NOTE: fever take some time to respond regardless of antibiotic use failure to defervesce is not a reason to change antibiotics if sensitive
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Rickettsia: Common infection in travellers to games parks in southern Africa
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RicketssiasRickettsia Africae Conorii Typhi Orientia
Tsusugamuyi
African tickbite fever
Mediterranean spotted fever fever
Murine typhus Scrub typhus from Asia
Transission Catle ticks Dog tick Rat fleas Mites
Distribution Sub-saharan African and safari park in southern Africa Eastern Caribean
Mediterranean and Caspian Litoral, Middle East , Indian subcontinent and Africa
Tropical and subtropical areas in port cities where the rodent population is dense
Rural South Asia (Laos)South East AsiaWestern pacificInfrequently report by travellers
Complications Fatal 32% Fatal 2% If untreated:Pneumonitis, CID,ARF and Meningoencephalitis
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Common presentation• Incubation: 5-7 days (up to 10 days)
• Non specific fever, head ache , mialgia, inoculation echar/rash and lymphadenitis
• Consider other causes of fever and skin lesions wich resembles echar:
Antrax
African Trypanosomiasis (chancre at site of tsetse fly bite)
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R Africae: multiple
R Conorii: single
R Typhi
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Investigations• Treatment should be started on suspicion :
- illness onset within 10 days
- exposure to tick in game park
- fever and headache with or without rash
• Doxycyxline 100 mg bd for 7 days or 48 hs after fever defervescence
• Confimation IFA paired initial and convalescence –phase serum sample
• If wider differential is considered: Cipro or Azithromycin
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Arbovirus infection
• Commonest arboviral infection in returning travellers to the UK are Dengue and Chikungunya
• Incubation: 4 – 8 days (range 3-14)
• Distribution: Asia and south America
• Repoted >100 countries and annual global incidence 50-100 million per year
• Transmission: Aedes aegypty
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Clinical presentation• Mild febrile illness
Headache- retro-orbital pain
Myalgia - arthralgia (> back pain)
Rash 1st erythrodermic
2nd petechial
Bleeding gums, epistaxis and GI bleed
Rarely hepatitis, myocarditis, encephalities
and neuropathies
Convalescence desquamation and post viral fatigue
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Dengue
2 days later
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Dengue diagnosis and treatment
• Positive PCR or if symptoms> 5-7 days +IgM ELISA
• Retrospective > 4 fold ↑ Ig G by haemoaglutination inhibition test
• UK reference laboratory services: HPA Special Pathogens reference Unit, Poton Down
• Treatment identify those patients at high risk of shock with daily FBC and platelets.
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Acute Schistosomiasis
• Katayama fever
• Incubation: 4-6 weeks ( range 3-10 weeks)
• Distribution: Africa (Asia- South America)
• Transmission: Swimming in lakes or rivers
Cercariae release from snails penetrates intact skin
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Clinical presentation
• Non specific signs and symptoms (? immune complex phenomenon)
fever myalgia arthralgia
lethargy cough/wheeze headache
rash ↑Liver/spleen diarrhoea
• Investigations:
eosinophilia
egg urine-stools
minority serology + seroconversion
0-6 months)
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Treatment• Diagnosis:
Fresh water exposure 4-8 weeks previously
Fever-Urticarial rash-Eosinophilia
• Treatment empiric!!!!
• Praziquantel
2 doses 20 mg/kg, 4-6 hs apart (Mature Schistosomes)
Repeat after 3 months ( Immature schistosomes)
• Short course of Steroids may alleviate acute symptoms
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Leptospirosis
• Distribution: Worldwide including UK
(> tropical and subtropical regions)
• Risk: exposure to fresh surface water, rodents (infected urine)
sports events
river rafting
rescue efforts after flooding
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Leptospirosis clinical presentation
• Incubation : 7 – 12 days (range 2-30 days)
• Initial phase: “flu like symptoms” lasting 4-7 days
• Immune phase: “Weil’s disease”
1-3 days later
fever, myalgia (calves)
haepatorrenal syndrome
haemorrhages
Conjunctiva suffusions suggestive
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Other manifestations
• GI: V-D, loss appetite, jaundice and hepatomegaly, liver failure, pancreatitis and GI bleed
• Respiratory: Cough + SOB
• Meningitis
• ARF
• Myocarditis
• Haemorrages – may confuse DHF
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Investigations
• Urinalysis proteinuria/haematuria
• FBC PMN leucocytosis
Thrombocytopenia
Anaemia
• Clotting normal (capillary fragility)
• LFT high bili + mildly raised ALT
• U&Es ARF
• Serology IgM titre > 1:320 (early infection)
> 10 days after symptoms send for IgM ELISA+ Microscopic agglutination MAT to confirm diagnosis
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Treatment
• Upon suspicion
• Penicillin and tetracycline antibiotics during bacteraemia phase
• Un well patients and Weil’s disease need renal and liver support
• Severe diseases is probably immunologically
mediated ( ? Benefit from antibiotics)
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Amoebic Liver Abscess
• Incubation: 8-20 weeks ( up to a year)
• Distribution : Worldwide > developing countries
• Presentation: 67-98% Fever
72-95% Abdominal pain
43-93% Haepatomegaly
20% PMH dysentery
10% diarrhoea on diagnosis
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Investigations• FBC neutrophil leucocytosis > 10 X 10 6 L
• LFT dearranged ↑↑ Alk Pho
• CRP/ESR raised
• Indirect haemagglutination >90% sensitivity
• Stoolsnegative
• CxR Raised hemi-diaphragm
• USS DD piogenic abscess (percutanous aspiration) R/O Hydatidic disease first!
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Amoebic Liver abscess
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Treatment• Start empiric treatment in patients with suggestive
history, epidemiology and imaging
• Metronidazole 500 mg tds orally for 7-10 days ( Cure in 90%)
• Tinidazole 2 g daily for 3 days (less nauseas)
• Follow treatment with 10 days luminal amoebicide to reduce relapse.
• Furoate 500 mg tds or Paromomycin 30 mg/kg per day in 3 divided doses
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Brucellocis
• Incubation: 2-4 weeks (up to 6 months)
• Distribution: world-wide ( Middle East, URRS, Balkan Peninsula and Mediterranean basin)
• Transmission: infected unpasteurised milk products. Farmers, vets with contact infected parts.
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Clinical presentation
• Fever Commonest presentation
acute with rigors or
chronic low grade relapsing
• Lymphadenopathy
• Hepatosplenomegaly
Complications:
• Osteoarticular disease
OA: knees, hips, ankles and wrists
Sacroillitis lumbar spine
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Other complications
• Epididymo-orchitis
• Septic abortions
• Neurological: meningitis encephalitis brain abcess
• Endocarditis: Aortic valve and requires early surgery
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Investigations and treatment
• LFT: mild transaminitis
• FBC: pancytopenia
• Bone marrow: gold standard
• BCM: sensitivity 15-70% (prolong cultures up to 4 weeks)
Note: Q Fever, rarer, similar from same area
Serology is key diagnosis!!
• Treatment: Doxycycline and Rifampicin 6-8 weeks + amynoglucosides 2 weeks
• Relapse 10 %
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HIV
• Prevalence in tropical countries is high 1/3 sexually active population and not restricted to high-risk groups
• 5-51% travellers take part in casual sex while abroad
• HIV seroconversion and syphilis can present as febrile illness
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Hepatitis
• Incubation: A 15-50 days
B 60-110 days
E 14-70 days
• Transmission A-E faecal-oral (water, food:shellfish and direct contact)
B sex-blood
Diagnosis IgM
Traetment Supportive
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Fever an respiratory symptoms• Upper respiratory tract infection: viral, St.Pneumonia, H
Influenza, Grup A steptoccoi
Diphteria in traveller returning from URRS, India, South East Asia and South America
• Lower respiratory tract infections:
HIV related PCP
Bird flu
TB (prolonged visits to families and friends) Histoplasmosis/ Coccidioidomycosis risk activities with dust and bats in caves in America
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Initial treatment for “bird flu”
• Isolate
Respiratory isolation ideally negative pressure
• Samples NPA & nasal swab PCR
• Inform
Local: ICT/Virology/ID
Regional: HPA/CCDC
• Treat: Oseltamivir/Zanamavir
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Fever and Neurological Symptoms• 15 per 1000 ill returned travellers
• Most common: Malaria and meningitis
• Encephalopathy: P falciparum,typhoid and HIV seroconversion
• Encephalitis with or without fever
Common causes in UK +
Arboviruses Brucellosis
Rabies Rickettsias
African trypanosomiasis
Discussion with virologist or reference laboratory
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Key points
• Think of the 5 Ws
• Risk factors for disease
• Don’t miss…
– HIV (risk group)
– TB (risk group)
– Malaria (knowledge of travel)
– Enteric fever (knowledge of travel)