Fever In The Returning Traveller Flashcards
What are the least common dx for imported fever?
Resp infection
UTI
What are the remaining dx for imported fever?
Diarrhoeal disease non typhoid Enteric fever typhoid Dengue fever Hep TB HIV seroconversion
What are the important questions to ask in evaluating imported fever?
What infections are possible given exposure?
Which infections are more probable given clinical findings?
Which infections are treatable or transmissible?
What should be asked in a travel history?
Where did you go? When did you go and come back? When did the symptoms begin? Urban or rural areas? What was the purpose of your travel? What pre travel vaccines/malaria prophylaxis did you take?
What pre travel advice can be included?
Vaccines- hep B, hep a
Yellow fever, Japanese b encephalitis can cross react with other Flaviviral serology
Meningitis hajj/ Africa A/C/W135
Typhoid vaccine not completely protective
Remember measles, rubella, diphtheria, pertussis, polio, tetanus
Malaria- no prophylaxis 100% effective
What diseases have an incubation period of longer than 3 weeks?
Hepatitis HIV Typhoid TB Malaria, schistoma, amoebic liver abcess, filaria
Which diseases have an incubation period from 10-21 days?
Malaria Enteric fever Rickettsia Brucella Leptospirosis VHF if in endemic area
Which diseases have an incubation period of less than 10 days?
Enteric fever Dengue Chikungunya Influenza Typhus VHF Malaria
What diesease is likely with fever, rash and LNs?
Rickettsia
What disease is likely with bites and rashes from animals?
Rabies
What diseases are likely from water exposure?
Leptospirosis
Schistsomiasis
What diseases are likely from sexual contact?
HIV
Syphilus
STI
What diseases are likely from food, meat milk cheese?
Brucellosis
E. coli
Toxoplasmosis
Raw fish- paragonimiasis
What diseases are likely from animals?
Avian flu
MERs cov
VHF
What diseases are likely from contact with sick people or funeral visit?
Flu
MERs
VHF
What is VHF?
Highly infectious, high mortality
Incubation period less than 21 days
Haemorrhage not always present eg Ebola virus disease
Non vaccines
What are the risk factors for VHF?
Unexplained deaths in region Traditional funeral rites Bush meat Cave exploration Healthcare workers
What is the fever pattern with dengue?
saddle back
2 temps, with a febrile 1-3 days in between
What are the fever patterns with malaria?
48 hours- p falciparum, vivax, ovale
72 hours- malariae
What should be particularly noted in a clinical exam?
Rash Jaundice LNs Hepatosplenomegaly Eschar Haemorrhage
What are the initial ix?
Blood films- malaria and antigen tests Blood cultures Serology for HIV, hepatitis Imported fever service at RIPL, porton down (arbovirus, flavivirus, rickettsia) FBC, UE, LFT, CRP Resp samples isolate Radiology
What diseases commonly present with systemic febrile illness?
Malaria
Dengue
Typhoid
What diseases commonly present with diarrhoea?
Usually self limiting but if prolonged, giardiasis
What diseases commonly present with skin complaints?
Rickettsia
Arbovirus
Cutaneous larva migrans
What diseases commonly present with resp illness?
Influenza H5N1 H7N9
Mers
What percentage of fevers have no cause identified?
25%
How is malaria transmitted?
Bites of anopheles mosquito
What are the 5 types of malaria?
Falciparum- can cause severe malaria, more than 1 million death pa, 3-4000000 infected
Ovale and vivax- can cause relapsing malaria
Malariae
Knowelsi- Borneo, severe and rapidly fatal disease
What are the risk factors for malaria?
Travel Rural more than urban Low standard of sleeping accommodation Lack of preventative measures Long duration of stay
What is the incidence of malaria?
UK imported- 2000 a year 75% falciparum
Africa- more than 90% falciparum
200-300 cases of severe malaria in UK, mortality up to 8 %
Resistance to chloroquine of falciparum almost universal
What are the clinical features of malaria?
7 days-3 months post exposure
Fevers, myalgia, headache, shivers/rigours, GI tract problems
What details are need for malaria film?
thick and thin
Takes at least 1 hour to perform and interpret
At least 3 negative films over 48 hours, malaria unlikely
Need parasite count and stage to assess severity
What is needed for the antigen malaria test?
Rapid, simple to perform and interpret
10-100 times less sensitive than thick film in best hands
May be positive in previously treated malaria
PCR most sensitive but not routinely available
What is the sequlae for falciparum?
Mild- parastaemia, no schizonts
Temp- less than 39 degrees
No complications
Severe- parastaemia, schizonts, non ambulant,
Complications- shock, renal failure, pulmonary oedema, severe anaemia (Hb
What is the treatment for uncomplicated falciparum?
Quinine 600 mg tds po plus doxycycline 100 mg od po 7 days or clinda 450 mg tds if pregnant
What are the adverse effects of standard malaria medication?
Nausea, deafness, tinnitus
Complete 7 days of rx
Monitor blood glucose
What are the alternative regimes of malaria treatment?
Riamet- 4 tabs at 0, 8,24,36, 48, 60 hours
Malarone- 4 tabs od for 3 days
What is the treatment for severe falciparum?
IV quinine 20mg/kg over 4 hours loading dose (omit if taking oral quinine derivative (chloroquine, mefloquine)
10mg/kg IV tds to follow
Arrhythmogenic and causes hypoglycaemia
Cardiac and BM monitoring mandatory
What is artemisinins?
Derived from plants
Used by Chinese herbalists for more than 2000 years
Synthetic derivatives: artesunate water soluble, artemether lipid soluble
Highly effective antimalarials with rapid parasite clearance
Recommended in combo with other drugs
What are the benefits of IV artesunate?
More effective and better tolerated than quinine
Effective against parasite ring forms, faster reduction in parastaemia
Potentially reduces sequestration
Benefit greater with higher parasite load
Recommended as 1st line for severe malaria, not licensed in UK
How is non falciparum treated?
Chloroquine effective
For vivax and ovale give primaquine to eradicate hypnozoites
Check g6pd level before giving primaquine and it is contraindicated in pregnancy and breastfeeding
What is the ABCD of malaria prevention?
Awareness of risk
Bite prevention
Chemo prophylaxis
Diagnose promptly
What is enteric fever caused by?
Salmonella typhi, paratyphi Gram negative bacilli, acid tolerant Spread by contaminated food, water, unsanitary conditions No animal reservoir Incubation period- 7-14 days
What are the symptoms of enteric fever?
Fever, stepwise Relative bradycardia Abdominal pain and colic Constipation Cough Rose spots Leukopenia, borderline thrombocytopenia Mild transamintis chronic carriage important for spread and persistance
What are the ix for typhoid?
Isolate patient Blood and stool cultures Inform lab of risk Stool culture positive in 90% in 1st week of illness More than 3 blood cultures Bone marrow and aspirate most sensitive
What is the mx for typhoid?
Start IV ceft and gentamicin if shocked
Discuss with id
Notify public health
What is dengue fever?
Transmitted by aedes aegyptii and aedes albopictus Mosquitos
Day time biting and prevalent in urban areas
Short incubation 1 week
Myalgia, break one fever, retro orbital pain
Sunburn like rash
What is the clinical course for dengue?
Defevescence around day 4-5
Complications may also develop at this time
What is the management for dengue fever?
Exclude malaria
Serology for dengue fever plus or minus PCR
Generally uncomplicated, supportive rx
Refer to infection specialist
What is the most common dx for imported fever?
Malaria
