Fever In Returning Traveller

Question 1

Which travel-acquired infections typically have a short incubation period (onset < 2 weeks)?

Answer 1

Dengue
Chikungunya
Traveller’s diarrhea
Malaria

Question 2

What is the organism that causes Mediterranean fever (AKA Malta fever)?

Answer 2

Brucellosis

Question 3

What is the most common method of infection with Brucellosis?

Answer 3

Consumption of unpasteurized dairy products, such as raw milk, soft cheese, etc.

Question 4

What are the clinical manifestations of Brucellosis (4)?

Answer 4

(1) Constitutional symptoms & fever (sweats can have a strong, mouldy odour)
(2) Arthralgias & Arthritis
(3) Hepatospenomegaly & lyphadenopathy
(4) GU involvement common (orchitis, cystitis)

Question 5

Which type of malaria may present years later due to hypnoziotes in the liver?

Answer 5

(1) P. Ovale

(2) P. Vivax

Question 6

What is the purpose of the thick smear look for in the diagnosis of malaria?

Answer 6

The thick smear looks for ANY parasite to make the diagnosis.

Question 7

What is the purpose of the thin smear in the workup of malaria?

Answer 7

The thin smear identifies the degree of parasitemia (%) and is used to spectate the strain with staining.

Question 8

What blood smear regimen needs to be sent in the workup for malaria?

Answer 8

Thick and thin blood smears x 3, separated by at least 6 hours over a 24 hour period.

Question 9

What has the best negative likelihood ratio for ruling out malaria in a returning traveller?

Answer 9

Lack of fever

Question 10

What physical exam finding has the best + LR for malaria in a returning traveller?

Answer 10

Splenomegaly + LR 6.5

Question 11

What laboratory value has the highest + LR when you suspect malaria in a returning traveller?

Answer 11

Hyperbilirubinemia + LR 7.3

Question 12

What are the criteria for severe malaria (8)?

Answer 12

(1) Neurological dysfunction
(2) Resp: ARDS or pulmonary edema
(3) Heme: DIC or severe anemia < 50
(4) Hypoglycemia
(5) Acidosis (pH < 7.25, HCO3 < 15)
(6) Renal Impairment (Cr > 265)
(7) High Lactate
(8) High parasitemia (> 5% in non-immune adults or > 10% in immune)

Question 13

How would you treat uncomplicated malaria?

Answer 13

Depending on regional sensitivities from site of travel:

(A) Chloroquine
OR
(B) Atovaquone-Proguanil
(C) Quinine PLUS doxycycline

Question 14

How would you treat a complicated malaria infection?

Answer 14

(1) IV artesunate x 48 hours then:

(A) Atovaquone-proguanil OR
(B) Doxycycline OR
(C) Clindamycin

Question 15

What are the options for malaria chemoprophylaxis when travelling to an endemic area (3)?

Answer 15

(1) Chloroquine/Hydroxychloroquine when travelling to sensitive areas. Safe in preganancy.
(2) Atovaquone-Proguanil (Malarone)
(3) Doxycycline

Question 16

What are the classic features of Dengue infection (6)?

Answer 16

(1) < 2 weeks from travel return
(2) Fever
(3) Maculopapular rash
(4) Retro-orbital pain
(5) Myalgias (“break-bone fever”)
(6) Cytopenias

Question 17

What is the fetal defects are associated with Zika virus (4)?

Answer 17

Microcephaly
Intracranial Calcifications
Retinal & Hearing Abnormalities
Arthrogryposis (Multiple joint contractures)

Question 18

In which two areas is Zika virus most endemic?

Answer 18

Caribbean

South America

Question 19

When is testing for Zika virus indicated (2)?

Answer 19

Indicated in a relevant exposure and:

(1) Symptomatic within 3 days of arriving or 14 days of departing a high risk area.
(2) Symptomatic pregnant woman.

NO LONGER recommend screening of asymptomatic pregnant women.

Question 20

Which medication do you need to avoid in a returning traveller until Dengue is ruled out?

Answer 20

NSAIDs

Question 21

If a patient decides to travel to a Zika endemic area, what precautions can they take to prevent transmission?

Answer 21

Mosquito transmission, therefore:

Cover up
Light permethrin clothing
DEET
Bed Nets

Question 22

What precautions are required for a patient admitted with suspected Ebola?

Answer 22

Droplet & Contact

Impermeable neck to tow with N95 and face shield.