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Year 5 😊✌🏼 > Imported Fevers > Flashcards

Imported Fevers Flashcards

1
Q

Key elements of a travel history

A
  • where did you go? (be as exact as possible, include stop-overs, rural vs urban)
  • when did you go? (exact dates and timings of symptoms; ask first about last few weeks and then last few years)
  • why did you go? (VFR - visiting friends and relatives?)
  • what did you do? (activities / interactions)
  • what pre-travel vaccines/malaria prophylaxis did you take?
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2
Q

When do malaria symptoms present?

A

falciparum: within 1 month (7d - 3 months)

non falciparum: some months after (weeks to months)

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3
Q

Areas with viral haemorrhagic fever?

A

sub saharan africa

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4
Q

Areas with malaria

A

SSA
latin america and caribbean
south east Asia
central and South Asia

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5
Q

Incubation period of viral hemorrhagic fevers

A

3-21 d

most people develop Sx within 7-10d

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6
Q

VHF

A

viral hemorrhagic fevers

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7
Q

Ways to get exposed to tropical diseases?

A

ticks
animals
tsetse fly
cruise ships or resorts
freshwater
game park
inhalation of dust or faeces
sexual contact
contaminated food or water
raw food
unpasteurised milk
bush meat

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8
Q

MERS mortality in relation to sars-cov-2 and associated animal

A

much higher mortality

from camels

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9
Q

% poeple returning from SSA with tropical illness?

A

70%

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10
Q

What type of travel is at higher risk of tropical infections?
What infections are common from returnees in SE Asia?

A
  • Risk of tropical infection higher among VFRs (visiting friends and relatives)
  • Non-tropical were common among returnees from SE Asia (45%)
  • but enteric fever (34%) and dengue (20%) remain important
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11
Q

why are VFRs ar high risk of tropical infections?

A

may be in more rural areas
may not be as careful with prophylaxis
may think they have immunity but this immunity may have disappeared after not being in the country for some years

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12
Q

Risk assess for VHF

A

VHF within 21d of return
also check for malaria

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13
Q

undifferentiated fever

A

fever without focal signs where the fever could be coming from

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14
Q

RDT for malaria

A

now increasingly used

rapid tests

Paracheck-Pf® (detect plasmodial HRP-II)
OptiMAL-IT (parasite LDH)

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15
Q

falciparum malaria on smear

A

‘headphones’ - 2 black dots connected

more than one parasite in one RBC

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16
Q

Management of severe falciparum Malaria

A

IV artesunate

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17
Q

parasitaemia - why is it important to know in malaria?

A

will tell you if it is severe or not

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18
Q

which group is mainly affectedly deaths from malaria?

A

African children <5 account for 80% of all malaria deaths in the region

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19
Q

Malaria with greatest mortality

A

Plasmodium falciparum

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20
Q

Plasmodium vivax

A

the most common of the less virulent (non-falciparum) species

causes milder disease
dominant in endemic areas outside SSA e.g. southeast asia

causes tertian malaria (fever spikes every 48h)

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21
Q

plasmodium falciparum

A

most virulent and causese the most severe disease

dominant in Africa

commonest type of malaria

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22
Q

life cycle of malaria

A
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23
Q

Mx of malaria caused by P.vivax and P. ovale

A

chloroquine + primaquine (check G6PD first before giving primaquine)

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24
Q

Prevention and pre-travel advice in malaria

A

risk assess - geographical + individual (pregnancy/accommodation/season)

prevent mosquito bites (repellants/nets)

prophylaxis (malarone/mefloquine/doxycycline; varies by region)

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25
Q

Presentation of malaria

A

10-15d post bite in

cyclical fevers
chills, high fevers and sweats

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26
Q

What gives you a dx of severe malaria?

A

high parasitaemia (>2% // >5% in non immune or >10%) OR schizont
- altered consciousness with or without seizures
- respiratory distress or ARDS
- circulatory collapse
- metabolic acidosis
- renal failure, haemoglobinuria (blackwater fever)
- hepatic failure
- coagulopathy +/- DIC
- severe anaemia or massive IV haemolytic
- hypoglycamiea

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27
Q

Why not give too many fluids in malaria?

A

???

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28
Q

Schizont

A

RBC with multiple parasites in it

one schizont give you a diagnosis of severe malaria

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29
Q

Thick and thin blood smear

A

Field’s or Giemsa stain

Thick: screen parasites (sensitive)
think: identify species and quantify parasitaemia

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30
Q

Malaria antigen detection tests

A

Paracheck-Pf (detect plasmodial …)
OptiMMAL-IT (parasite LDH)

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31
Q

Management of malaria

A

Falciparum:
- severe: 1. artesunate IV 2. quinine IV
- mild: oral ACT (Riamet/Co-artem - artemisinin combination therapies, eat with fatty meals)

Non-falciparum
- chloroquine + primaquine (check G6PD)

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32
Q

Mx of severe malaria

A

ABCDEFG (correct hypoglycaemia, cautious rehydration avoiding overload, organ support)

IV artesunate In preference to IV quinine

Daily parasitaemia then PO follow on eg with ACT (artemesin combination therapy (riamet - Artemether + lumefantrine)

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33
Q

SE of IV quinine

A

cinchonism
arrhythmia
hyperinsulinaemia

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34
Q

SE of IV artesunate

A

delayed haemolysis (make sure to FU a few weeks after treatment!!)

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35
Q

What should you check before starting chloroquine + primaquine?

A

G6PD

otherwise can get severe haemolysis

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36
Q

What is dengue transmitted by?

A

Aedes mosquito

mainly: Aedes aegypti

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37
Q

How many seroptyeps of dengue?

A

4 (1-4)

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38
Q

where does dengue replicate?

A

midgut

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39
Q

prevention of dengue

A

use mosquito repellents
cover your skin (long sleeves, nets etc)

in people who have had dengue before: vaccination

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40
Q

climates with dengue

A

urban and semi urban
tropical and subtropical climamtes

early morning and dusk/twilight -> cover skin particularly then

Vaccine: Dengvaxia (licensed 2015, not for travellers, only for people who have had dengue before)

mosquito control (on a governmental etc level)

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41
Q

how many dengue cases of dengue in UK / year

A

340

NOTIFIABLE

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42
Q

Dengue incubation and disease duration

A

4-7 d incubation

duration 2-7 dy

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43
Q

sx of dengue

A

high fever (40)
severe headache (retro-orbital)
myalgia/arthralgia
N&V
blanching rash (sunburn, white when you press)
Maculopapular, measles-like exanthem (2-5d post fever onset)

thrombocytopenia

Most are mild/ asymptomatic – get better in 1-2 weeks but can be severe

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44
Q

testing for dengue

A

blood/urine PCR (after 4 days)

serology after 5-7d
- IgM: (cross reacts with other viruses
- IgA can be useful
- IgG not very useful

convalescent serology 2w later to check

RDT (rapid diagnostic tests - Not the best yet)

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45
Q

issues with dengue serology

A

X-reaction with other flaviviruses IgG (JE, yellow fever)

have to wait 5-7d to do serology

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45
Q

Vaccines for dengue

A

Dengvaxia
licensed in 2015
not for travellers

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46
Q

Figmothermic bradycardia

A

fever with no tachy / fever with bradycardia

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47
Q

Himalaya peak temperatures - which pathogen and what are they ?

A

typical of salmonella typhi

temperature goes up and down

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48
Q

What causes enteric fever?

A

salmonella typhi and paratyphi

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49
Q

transmission of enteric fever

A

faeco oral (only humans can be infected, no known animal reservior, some humans can be carriers (Typhoid Mary))

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50
Q

Diagnosis of typhoid fever

A

blood, BM and stool cultures

RDT - false +ve, used in low income settings only

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51
Q

where is enteric fever common?

A

10x more likely on Indian subcontinent

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52
Q

Clinical presentation of enteric fever

A

gradual onset of high, prolonged fever
headache
rose spots (rare)
constipation
dry cough

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53
Q

untreated typhoid course

A

week1: fever, fluctuations with bradycardia, malaise, headache, cough, epistaxis

week 2: extreme fatigue, high fever and plateau, bradycardia, delirium, raised ALT, HS-megaly

wee 3: complications: intestinal haemorrhage due to bleeding, congested Peyer’s patches, intestinal perforation in the distal ileum, septicaemia, resp complications, encephalitis

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54
Q

Which mosquito spreads malaria?

A

female Anopheles mosquito

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55
Q

Fever in a returning traveller - causes

A
  • tropical diseases (e.g. malaria, typhoid, dengue, VHF; bacterial disease e.g. cholera, E.coli)
  • common UK causes (UTI, Pneumonia, influenza)
  • STIs (e.g. HIV seroconversion)
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56
Q

Resource to check for current outbreaks

A

Promed
NaTHNaC / travel health pro

57
Q

Which type of salmonella is only seen in humans?

A

S. Typhi

it is NOT zoonotic
the only reservoir is in humans

58
Q

What are the different types of salmonella?

A

typhoidal
- S. typhi
- S. paratyphi

Non-typhoidal
- S. enteritidis
- S. cholerasuis
- S. typhimurium

59
Q

What type of pathogens are salmonella species?
What do they produce on a certain growth medium?

A

anaerobic gram -ve bacilli

produces H2S (hydrogen sulfide) on TSI agar

60
Q

how long does S. typhi vaccination last for?

A

3 years

61
Q

Who is the S. typhi vaccination recommended for?

A

traveling to high-risk areas (East and Southeast Asia, South and Central America, Africa

62
Q

How does typhoid fever present?

A

Incubation period: 6-30d

Week 1
fever fluctuations
Relative bradycardia
Constipation or diarrhea
Headache
dry cough

Week 2
Persistent high fever (no chills) and plateau- mostly unresponsive to antipyretics
Rose-spots (lower chest and abdomen) - 1/3
raised ALT
EPISTAXIS (in 25%)
Typhoid tongue: greyish/yellowish-coated tongue with red edges
Nonspecific abdominal pain and headache or RLQ pain (terminal ileum)
Yellow-green diarrhea, or obstipation and bowel obstruction (as a result of swollen Peyer patches in the ileum)
Neurological symptoms (delirium, coma) -> due to

Week 3
Clinical features of week 2
Additional possible complications include:
Gastrointestinal ulceration with bleeding and perforation
Hepatosplenomegaly
In rare cases: sepsis, meningitis, myocarditis, and renal failure

From week 4 improvement (or complications)

63
Q

What pathogen causes enteric fever?

A

S. typhi

64
Q

Pathophysiology of typhoid fever.

A
  • high infective dose (10^5 organisms) needed to cause disease (ORAL uptake)
  • uptake by Peyer’s patches in the distal ileum (migrates via M cells through the epithelium and into the Peyer patches)
  • Infection of macrophages → nonspecific symptoms (can survive IC -> facultative IC parasite with flagella)
  • Spread from macrophages to the bloodstream → septicemia → systemic disease
  • Migration back to intestine → excretion in feces
65
Q

transmission of salmonella

A

faeco-oral

S. typhi humans are the only reservoir

for other types can also get if from raw eggs/undercooked chicken
food prepared buy carriers
contaminated water

66
Q

Prevention of typhoid fever?

A
  • Sanitation & hygiene
  • Vaccination – partially protective for S.typhi but no cover for S. paratyphi
67
Q

Mx of typhoid fever

A

ORS (oral rehydration solution)

First Ceftriaxone IV
Then give Azithromycin PO
(depending on resistance)

68
Q

Complications of typhoid fever

A
  • GI perforation
  • septicaemia as a result of perf
  • encephalitis
  • respiratory complications
  • 2-5% Chronic salmonella carrier (increased risk of gallbladder cancer)
69
Q

Why is chronic carriage of salmonella an issue?

A

increased risk of gallbladder cancer

70
Q

Ix for typhoid fever

A

blood and stool cultures

FBC
LFTs (raised ALT)

71
Q

Distinguishing feature of enteric fever

A

Sphygmothermic dissociation (relative bradycardia)
+ fluctuating fever which then plateaus (not very responsive to antipyretics)

72
Q

Who is at increased risk of salmonella?

A

people with SCD/asplenic patients

  • are at increased risk of salmonella infections
  • can get salmonella osteomyelitis
73
Q

areas where travellers can get enteric fever from

A

tropics & subtropics

74
Q

distinguishing feature of anopheles mosquito

A

the only one that feeds with thorax in the air

75
Q

What are arboviruses and what are some examples?

A

viruses spread through can anthropod vector such as a mosquito (blood sucking)

RNA viruses

e.g. West Nile virus; Chikungunya; Zika; Dengue;

76
Q

subtypes of arboviruses

A

bunyaviridae (e.g. hantavirus, rift valley fever)
togaviridae (e.g. chikungunya)
flaviviridae (e.g. dengue, yellow fever, zika)

77
Q

Do you have to isolate someone with dengue?

A

no because you get it via mosquitoes

78
Q

is dengue notifiable?

A

yes

79
Q

Leptospirosis - which animal associated with?

A

rats

80
Q

Issue with dengue reinfection

A

risk: dengue haemorrhagic fever/dengue shock syndrome if infected with different serotype

Antibody dependent enhancement is the underlying mechanism

you get cytokine storm

rarely seen in travellers

81
Q

Mx of dengue

A

supportive

generally self limiting in 1-2 weeks

82
Q

Do travellers get dengue haemorrhagic fever?

A

generally no

they can get dengue but DHF is uncommon

83
Q

Do travellers get dengue haemorrhagic fever?

A

generally no

84
Q

What happens with a sample that you take with ?dengue/other tropical diseases?

A

gets sent to RIPL (rare and imported pathogens laboratory)

there they test for everything from the area the patient travelled to

you still give them some clinical information and what you suspect so that they can interpret the findings accordingly

85
Q

Why is dengue associated with water?

A

because mosquitoes (aedes) are found near water

86
Q

which blood bottle for malaria thick and thin films

A

EDTA (purple)

87
Q

Features of severe falciparum malaria

(RELEVANT FOR FINALS)

A

Impaired consciousness (GCS<15) or seizures
renal impairment
acidosis (pH <7.3)
hypoglycaemia (<2.2 mmol/L)
pulmonary oedema or ARDS
anaemia (Hb <8g/dL)
spontaneous bleeding/DIC
shock (BP <90/60 mmHg)
haemoglobinuria (without G6PD)
parasitaaemia >2% (WHO >10%)
pregnancy
vomiting

88
Q

what pathogen type causes malaria

A

plasmodium

= protozoal infection (unicellular eukaryotes)

89
Q

Life cycle of plasmodium (malaria)

A

involves mosquitoes (female anopheles) and humans (RBCs and liver; initial replication in liver then asexual reproduction in RBCs)

In humans: Erythrocytic and
Exoerythrocytic stages

Undergo asexual reproduction in the erythrocytes

90
Q

Features on microscopy of different plasmodium species

A

Falcip – double dotted rings (chromatin dots on some rings)

Vivax – schuffners dots may be present

Malariae – mature schizonts have daisy head appearance. Squarish appearance of ring forms

Ovale – enlarged red cells. Comet forms

P. knowlesi

91
Q

return from tropics, sunburn rash, low platelets, fever - dx?

A

dengue

92
Q

Malaria disease course

A

Infection → asymptomatic parasitemia → uncomplicated illness → severe malaria → death

93
Q

Which drug is used to eradicate
liver hypnozoites in P. vivax and
P. ovale malaria?

A

Primaquine

94
Q

The Plasmodium species associated with dormant hypnozoites in the
liver are….

A

Plasmodium vivax
Plasmodium ovale

95
Q

Which patients are relatively resistant to malaria?

A

sickle cell trait

96
Q

What are dormant malaria plasmodium stage in the liver called?

A

hypnozoite

97
Q

what pathogen causes anthrax? what type of pathogen is it

A

bacillus anthraces

gram-positive spore-forming bacterium

98
Q

Mx of anthrax

A

doxycycline / ciprofloxacin

99
Q

Signs of anthrax

A

pulmonary: massive lymphadenopathy + mediastinal haemorrhage

cutaneous: painless round black lesions + rim of oedema

100
Q

SE of RIPE

A

Rifampicin - orange secretions, raised ALT (if 5x upper normal stop, if 3x then monitor and continue)
Isoniazid - peripheral neuropathy
Pyrazinamide - hepatitis
Ethambutol - ophthalmoplegia, loss of colour vision (check CV before starting)

101
Q

what is a marker of someone with TB being infectious?

A

+ve auramine stain of sputum

102
Q

why are AFB test positive in TB?

A

they have a mycolic acid layer

in the test they are heated up, stain gets in and as the layer forms again the stain does not leave

in organisms without this layer the stain simply gets out

103
Q

Mx of latent TB

A

R+I for 3 months

OR

isoniazid for 6 months

104
Q

What if someone on TB meds is not getting better?

A

have a high level of suspicion for ddx

usually people respond well to anti-TB meds

also check for resistance

105
Q

common types of extra pulmonary TB

A

LN
CNS
peritoneal

106
Q

in what TB cases should you add prednisolone for treatment and how long?

A

CNS and pericardial TB

high dose pred for 6-10 w

107
Q

imaging in TB

A

CXR initially

often CT scan is useful

108
Q

what are the issues with strep pneumoniae blood cultures?

A

S. pneumoniae undergoes autolysis

additionally the best time to take blood culture is 1h before onset of fever and this would rarely be done

109
Q

What % people have Staph on their skin and what % of that is MRSA?

A

20%

20% of them

110
Q

mortality of S aureus sepsis

A

30-40%

111
Q

how caan you get Staph aureus sepsis?

A

IVDU
cuts/grazes
diabetic foot ulcers
psoriasis

112
Q

name g-ve rods

A

E coli
Klebsiella
citrobacter

113
Q

How long after TB Mx is initiated are patients hopefully no longer smear +ve and infective?

A

2w

114
Q

clinical presentation of chikugunya

A

Fever
!!joint pain (severe bilateral polyarthralgia)
periarticular oedema
headache
maculopapular 089 rash

115
Q

How can you get chikungunya>

A

Aedes mosquito (aegypti > albopictus).

Vertical

116
Q

causative agent of chikungunya and pathogen type

A

CHIKV.

Genus: Alphavirus of Family Togaviridae. RNA

117
Q

Mx of chikungunya

A

Mainly supportive.

Simple analgesics (paracetamol/ NSAID) but avoid aspirin.

118
Q

Ix for chikungunya

A

PCR or IgM

119
Q

What confection can you get in chikungunya?

A

dengue

both by aedes mosquito

120
Q

complications of chikungunya

A

Main is severe chronic arthralgia for weeks/ months

121
Q

Where is chikungunya seen

A

Widespread Africa, Americas, Asia

122
Q

Where is chikungunya seen

A

Widespread Africa, Americas, Asia

123
Q

incubation period for chikungunya

A

Inc: 3-7 days
(range 1-10)

124
Q

Which infections are associated with Guillain Barre syndrome?

A

Campylobacter jejuni
Zika

CMV
influenza
EBV
HIV

125
Q

Where are VHF mainly?

A

SSA

126
Q

Mx of leptospirosis

A

Antibiotics: doxycycline, ceftriaxone, penicillin

127
Q

Mx of Strep pneumonia sepsis

A

PENICILLIN

as high a dose as you can e.g. 12g/d BenPen

128
Q

Ix for leptospirosis

A

PCR of DNA in serum, urine, CSF

IgM ELISA (false positive with EBV, CMV, viral hepatitis)

129
Q

Epidemiology of leptospirosis

A

Tropical, subtropical & temperate

e.g. sewage/ after floods/ rural areas/ water sports

130
Q

transmission of leptospirosis

A

excreted in dog/rat urine

can invade abraded skin or mucous membranes

penetrates broken skin
mouth/eyes/nose/wounds
swimming in contaminated water

131
Q

What pathogen causes leptospirosis

A

zoonotic disease caused by gram-negative Leptospira bacteria (L. interrogans)

obligate, aerobic, motile spirochetes

many subgroups

can invade abraded skin or mucous membranes

132
Q

Sx of leptospirosis

A

early phase: mild and characterized by nonspecific symptoms (e.g., high fever, headache, and myalgia (thighs and lower back))

second phase: meningismus and raised WCC in CSF, correlattes with IgM generation

CONJUNCTIVAL HAEMORRHAGES

Most cases -> symptoms resolve spontaneously after 1/52

10% of cases -> disease progresses rapidly to a severe form (icterohemorrhagic leptospirosis, or Weil disease), which typically presents with a triad of jaundice, bleeding manifestations (haemorrhages in organs), and AKI
+haemolytic anaemia
+mental status change

133
Q

How do you get anthrax?

A

zoonotic infection

in: cows, goats, and sheep

transmission by contact with infected animals or infected animal products

134
Q

Lyme disease - how do you get it?

A

e.g. hiking

transmitted via ticks (Ixodes scapularis tick) - anthropod-borne

or deer

135
Q

Neuroborreliosis mx

A

IV ceftriaxone for 2-4w

136
Q

Mx of Lyme disease

A

doxycycline for 2-3 weeks

or: amoxillin, cefuroxime, azithromycin

137
Q

Lyme diseases dx

A

clinical (esp. if erythema migrans is present)

ELISA (sensitive) and Western blot (specific) antibodies for IgM (2-4 weeks) and IgG (4-6 weeks.)
PCR of blood/ CSF but imperfect.

138
Q

vector for lyme disease

A

Ixodes scapularis

also: deer

139
Q

What pathogen causes lyme diseases?

A

Borrelia spp. (spirochaete - bacteria)

e.g. burgdorferi in USA (other types more common in Europe and asia i.e. B. afzelii and B. garinii)

140
Q

Presentation of lyme disease

A

Can be asymptomatic

Early localized infection: in 80% this is Erythema migrans rash – can be large and then clear centrally ‘bull’s eye rash.’ May have viral symptoms.

Early disseminated infection: through blood/; lymph – in 10-20% rah, myalgia, arthralgia. 10-15% untreated get neuroborrleiosis – lymphocytic meningitis, cranial neuritis, radiculopathy, mononeuritis multiplex
May cause heart Lyme carditis: palpitations, dizziness, fainting, HF

Late disseminated infection: after several months; multisystem. In 60% of untreated can lead to join pain/ effusions/ Lyme encephalopathy/ encephalomyelitis. ACA – Acrodermatitis chronica atrophicans

Year 5 😊✌🏼 (53 decks)

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