1. Fever in the Returning Traveller Flashcards
What is the most common diagnosis for travellers with fever?
The second, third and fourth most common diagnoses for travellers with fever are malaria, acute diarrhoeal disease, and respiratory illness. Give causes for each.
What is the fifth most common diagnosis?
Unspecified febrile illness
Malaria: P. falciparum, P. vivax
Acute diarrhoeal disease: Traveller’s diarrhoea, Campylobacter, non-typhoidal Salmonella, Shigella
Respiratory illness: bacterial pneumonia, tonsillitis, flu-like illness
Dengue
What are some general considerations for a returning traveller with fever?
When do most tropical infections become symptomatic?
What would you consider for a travel history?
Thorough history (travel and non, time of onset, symptom duration), VHF risk assess, thorough clinical exam, malaria film, admit anyone with danger signs, remember non-tropical infections e.g. flu, bacterial meningitis and non-infectious causes e.g. DVT, appropriate PPE and isolation, notification
Within 21 days of exposure (most present within 1m of leaving endemic area)
Where, when, why, what (exposures), who, preventative measures/empiric therapy (e.g. malaria prophylaxis (and where was it obtained - may be fake/weaker), vaccination, compliance, any treatment out there)?
What are the top 4 most common causes of fever in returning travellers from sub-saharan Africa?
What things may cause VHF?
What two conditions would cause you to consider VHF? What things would indicate a high possibility?
Malaria, dengue/chikungunya, rickettsiae, enteric fever (typhoid). Also check for HIV and viral haemorrhagic fever
Lassa (low background rate), Ebola (epidemics), Marburg, CCHF (tick transmitted)
Fever AND visited endemic area <21d
High possibility if: contact with/care for febrile person (>4h), health care/lab/vet work, contact with cases/outbreak/animals, shock, organ failure, haemorrhage
How would you initially manage VHF?
What are the top 5 most common causes of fever in returning travellers from South and Central Asia?
Top 4 most common for South East Asia?
Top 4 most common in Latin America and the Caribbean?
Malaria film, clotted blood, EDTA blood (for VHR PCR), isolation, PPE, infection control (<em>e.g. gloves, facemask, respirator, double gloves if worse symptoms</em>), discuss with infectious diseases/microbiology, virologist, CCDC (public health), list of contacts
Dengue, enteric fever (typhoid), malaria, chikungunya, TB. Then rickettsiae
Dengue, enteric fever (typhoid), chikungunya, malaria. Then leptospirosis
Dengue/Chikungunya/Zika, enteric fever (typhoid), malaria, brucellosis
Give examples of diagnoses that have the following incubation periods:
a) short <10d
b) medium 10-21d
c) long >21d
What infections are people visiting friends/relatives in developing countries at a greater risk of getting than tourists?
a) bacterial/viral gastroenteritis, dengue, chikungunya, zika, respiratory tract infection, UTI, meningitis, rickettsia
b) malaria, typhoid, rickettsia, EBV, CMV, HIV, leptospirosis, VHF, trypanosomiasis, endemic fungi (histoplasmosis)
c) malaria, HIV, hep A-E, TB, acute schistosomiasis, amoebic liver abscess, brucellosis, visceral leishmaniasis, trypanosomiasis
Malaria, typhoid, TB, hep A, STIs inc. HIV
What could the following specific exposures lead to?
a) Fresh/brackish water
b) swimming/rafting in fresh water
c) game park/safari (3 things)
d) animal contact/bites
e) caves
f) unprotected sex
a) acute schistosomiasis (2-12w post exposure, eosinophillia, swimmer’s itch)
b) leptospirosis (<4w post exposure, jaundice, liver/renal impairment)
c) tick typhus (eschar, necrotic centre, maculopapular, tx = doxycycline), trypanosomiasis (painful tsetse fly bite? chancre? lymphangitis), anthrax (necrotic ulcer and oedema, from contact with animal hides, if inhaled -> pneumonia)
d) rabies, brucella, Q fever, VHF
e) histoplasmosis, rabies, ebola
f) HIV, syphilis, viral hepatitis, gonococcaemia, STI
What would you look for in a clinial examination of a returning traveller with fever?
What investigations would you do?
How might you interpret the following FBC:
a) lymphopenia
b) low-normal
c) neutrophilia
d) thrombocytopenia
e) eosinophilia
General (jaundice, anaemia), danger signs (mental status, meningism, respiratory distress, shock, liver/renal impairment), lymphadenopathy (never with malaria), skin (rash/eschar/ulcer/vesicles/urticaria), hepato/splenomegaly
Malaria film/ICT (x2 over 2d), FBC, U&Es, LFTs, CRP, blood cultures x2, serology, EDTA for PCR e.g. Dengue, urinalysis, stool, CXR
a) viral infection, dengue, typhoid, HIV
b) viral, typhoid, malaria, rickettsial
c) bacterial, amoebic
d) dengue, typhoid, malaria, sepsis
e) schisto, fasciola, filaria, strongyloides, drug reaction
How is malaria diagnosed?
What are some markers of severe malaria (Plasmodium falciparum)?
How is malaria treated? (Severe P.falc vs uncomplicated P.falc vs vivax/ovale)
Thick and thin blood film (gold std), rapid diagnostic tests (RDTs) detect Plasmodium spp. antigens. (Parasitaemia may be low if taking prophylaxis/pregnant).
Parasitaemia ≥10%, cerebral involvement e.g. seizures, respiratory involvement (pulmonary oedema etc.), shock, bleeding/DIC/platelets <20, anaemia (Hb <8), hypoglycaemia, renal failure, haemoglobinuria, acidosis (pH <7.3). ICU ADMISSION!
Severe P. falc: IV Artesunate (preferred) OR IV Quinine (+ cardiac and BG monitoring), oral therapy once improved. Check blood film daily.
Uncomplicated P. falc: Malarone, Riamet, Quinine and doxycycline. Non-falciparum (vivax/ovale): choroquine then primaquine
What conditions do the following photos suggest?
a) acute schistosomiasis - eosinophillia
b) tick typhus - eschar, maculopapular, central necrosis
c) trypanosomiasis - lymphangitis, chancre
d) anthrax - necrotic ulcer and oedema
What are the commonest arboviruses (arthropod-borne) in returning travellers?
What can dengue cause? What are typical features? What are some warning signs?
How is dengue diagnosed?
How is it treated?
Dengue, chikungunya, zika. Can present as systemic febrile illness, haemorrhagic fever, encephalitis/arthritis
Spectrum: mild febrile -> haemorrhagic fever and shock. Typical: febrile, headache, myalgia, arthralgia, rash initially erthyrodermic and later petechial. Warning signs: abdo pain, vomiting, hepatomegaly, mucosal bleed, lethargy, increase in HCT and decrease in platelets
Day 0 - PCR or viral antigen e.g. NS1. Around day 3 - Ab detection: IgM and IgG ELISA
Simple analgesia (avoid NSAIDs - renal impairment risk), monitor, daily FBC, fluid balance, WHO guidance
What are some symptoms of chikungunya, how is it diagnosed and treated?
What is typhoid and paratyphoid? How is it diagnosed and treated?
What does rickettsia classically present with? How is it treated?
Fever and severe arthralgia, Dx: PCR or IgM, Tx: symptomatic relief, steroids for refractory arthritis
Caused by Salmonella typhi/paratyphi, fever + non-specific symptoms, complications incl. GI bleed, encephalopathy. Dx: FBC may be normal but decreased WBC and platelets, blood, stool and urine culture, WIDAL TEST UNRELIABLE. Tx: IV ceftriaxone while awaiting sensitivity results, if sensitive - oral ciprofloxacin. Or azithromycin. Isolation!
Tick typhus. Fever, headache, rash, myalgia. Sometimes eschar and lymphadenitis. Tx: doxycycline while waiting serology. Alt = azithromycin
What is this condition? What stage?
Dengue
A) Erythrodermic (early)
B) Petechial with ‘white islands’ (late)
List some things that may cause:
a) undifferentiated fever
b) fever and respiratory symptoms
c) fever and jaundice
a) malaria, typhoid, dengue/chickungunya, rickettsiae, acute schistosomiasis, leptospirosis, amoebic liver abscess, brucella
b) sinusitis, tonsillitis, bronchitis, influenza, pneumonia, TB, legionella, MERS/SARS
c) hep A-E, malaria, leptospirosis, typhoid, yellow fever, typhus, EBV, CMV, VHF, sepsis, haemolysis, sickle cell crisis
