Fever in the returning child traveller: Highlights for health care providers Flashcards
Which group of people are at highest risk of infection from travelling?
visiting friends and relatives (VFRs)
Because:
- less likely to seek pre-departure advice and more likely to travel for longer periods
- more likely to be exposed to local food, drink, and infectious contacts for longer periods
- often underappreciate the severity of certain endemic infections
- often underappreciate that immunity to malaria wanes over time
What are the components of the travel history?
- ask about travel outside of Canada in previous 12 months
- Pre-travel preparation: counselling, vaccinations, malaria chemoprophylaxis, PPE (clothing, insect nets and repellant)
- Travel details and disruptions: destinations, dates, timing of symptom onset
- Setting: rural vs urban, living conditions, altitude, season (ie rainy or dry)
- Activities: VFR or professional, community involvement, environments
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Potential exposures:
- food consumption and handling/preparation (risk for exposure to unpasteurized dairy, meat, seafood)
- drinking water and fresh water sources (ie for swimming, washing)
- sick contacts
- insect bites (esp mosquitos, ticks)
- animal bites or animal exposures
- sexual encounters
- Medical care: health care contacts and medication received while travelling and since return
What are Host risk factors for travel related illness?
- being unvaccinated or incompletely vaccinated
- hx of compromised or suppressed immunity (splenic dysfunction)
- low wt or poor nutritional status
- young age (<1 mo)
What are the travel related organisms that can be asosciated with jaundice?
What are the travel related organisms that can be associated with lymph node enlargement?
What are the travel related organisms that can be associated with diarrhea?
What are the travel related organisms that can be associated with hepatomegaly and splenomegaly?
What are the travel related organisms that can be associated with:
- hemorrhagic rash
- fever and rash
What are the travel related organisms that can be associated with
- fever and low white count
- fever and eosinophilia
What are the travel related organisms that can be associated with fever onset >2 wks and <2 wks?
What are the 3 most important DDx for fever in a returning traveller?
- Malaria (20-30% of cases; onset within 6 mo of return)
- Travellers diarrhea (10-20%) and enteric fever (2-7%) - onset within 60 days of return
- Dengue (5%) within 14 days of return
- other infections: chikungunya, zika, viral hemorrhagic fever (Ebola), coronaviruses (Middle East Respiratory Syndrome-CoV)
How do you treat a child with suspected P falciparum?
- all children and youth with suspected P falciparum should be admitted to hospital and treated for chloroquine-resistant malaria until speciation available
- urgent consult with ID expert
- artesunate or quinine
mortality rate 20% for plasmodium falciparum
What does the lab work of someone with Typhoid fever show?
leukopenia and thrombocytopenia
BCx is important for diagnosis (more than one sample may be required)
What are the etiologies for traveller’s diarrhea in:
acute < 2 wks
chronic > 2 wks
acute (<2 weeks): rotavirus or bacterial
chronic (> 2 weeks): post-infectious diarrhea, giardiasis
Tx: Antibiotics if stools are bloody
What is caused by mosquitoes that bite at night vs in the day?
day: dengue
night: malaria
Dengue fever:
What can repeat infections present as?
What does labwork show?
Management?
Repeat infections can present as: hemorrhagic dengue or as shock syndrome (with hypoNa, hypoproteinemia, circulatory collapse)
Labwork: lymphocytosis, neutropenia, elevated aminotransferases
Management:
- supportive, rest, fluids, antipyretics, analgesia, transfusion
- rule out sepsis and malaria
- avoid NSAIDs, steroids due to bleeding risk
What medications do you need to avoid in Dengue?
avoid NSAIDs, steroids due to bleeding risk
What investigations should you do for returning traveller with fever?
- CBC with diff, LET, lytes, Cr
- malaria smears +/- antigen detection testing when available
- (at least 2 subsequent samples over 24-48 hours when child has visited a malaria-endemic area)
- Blood Cx
- UA +/- UCx
Consider:
- stool culture for enteropathogens (YSSEC)
- CXR
- Stool for O&P (chronic diarrhea or immunocompromised) - cyclospora, cryptosporidium, E histolytica, giardia
- Viral serology: acute and convalescent serology should be saved and run if no dx within 10-14 days
- dengue if fever onset within 14 days from S Asia, SE Asia, Latin America, or caribbean
- Chikungunya serology: SEA, Latin America, Caribbean
- Zika or arboviruses
How would you manage an unwell appearing traveller with fever?
Think about P. falciparum!
- empirically tx for P falciparum malaria if child unwell or lab diagnosis may be delayed, including broad spectrum abx with G- coverage
- Remember: malaria can present as co-infection with pneumonia or bacteremia
What is the incubation period of the DDx for fever in returning traveller?
- Malaria: onset within 6 mo of return
- Travellers diarrhea and enteric fever - within 60 days of return
- Dengue - within 14 days of return
