Infections

Question 1

Fever in returning travellers: Initial Assessment

Answer 1

Initial Assessment
PERSON, PLACE, TIME, SYMPTOMS PERSON : Purpose/duration of travel
Immune status
Prophylaxis
PLACE : Destination / setting / activities
TIME : Timing of exposure /Onset of symptoms (knowledge of incubation periods)
SYMPTOMS : Undifferentiated/localising

Question 2

Fever in returning travellers: Malaria film

Answer 2

· Perform in all patients who have visited a tropical country within 1 year of presentation
· The sensitivity of a thick film read by an expert is equivalent to that of an RDT, however blood films are necessary for speciation and parasite count
· Three thick films / RDTs over 72 hours (as an outpatient if appropriate) should be performed to exclude malaria with confidence
· Blood films (thick and thin) should be sent to the reference lab for confirmation

Question 3

Fever in returning travellers: FBC

Answer 3

· Lymphopaenia: common in viral infection (dengue, HIV) and typhoid
· Eosinophilia (>0.5 x 103ul): incidental or indicative of infectious (e.g parasitic, fungal) or non-infectious cause · Thromobocytopaenia: malaria, dengue, acute HIV, typhoid, also seen in severe sepsis

Question 4

Fever in returning travellers: Blood cultures

Answer 4

· Two sets should be taken prior to antibiotics

· Sensitivity of up to 80% in typhoid

Question 5

Fever in returning travellers: U&E, LFTs

Answer 5

High transaminases – viral hepatitis Isolated

ALP – amoebic liver abscess

Question 6

Fever in returning travellers: Serum save

Answer 6

· HIV should be offered to all patients with pneumonia, lymphocytic
meningitis, diarrhoea, unexplained fever
· Other e.g. arboviral, brucella serology if indicated

Question 7

Fever in returning travellers: Urinalysis

Answer 7

· Proteinuria and haematuria in leptospirosis · Haemoglobinuria in malaria (rare)

Question 8

Fever in returning travellers: common conditions from Sub-Saharan Africa

Answer 8

Malaria, rickettsial infection (tick typhus)

Question 9

Fever in returning travellers: common conditions from South and central Asia and south east Asia

Answer 9

Dengue, enteric fever, malaria

Question 10

Fever in returning travellers: Infections with a short incubation period (<10 days)

Answer 10

Acute gastroenteritis (bacterial, viral)
Arboviral infections, e.g. dengue, chikungunya Meningitis (bacterial, viral)
Relapsing fever (Borrelia spp.)
Respiratory tract infection (bacterial, viral including influenza)
Rickettsial infection, e.g. tick typhus, scrub typhus

Question 11

Fever in returning travellers: Infections with a medium incubation period (10-21 days)

Answer 11

Bacterial
C Brucellosis
C Enteric fever (typhoid and paratyphoid fever)
C Leptospirosis
C Q fever
Fungal
C Coccidioidomycosis
C Histoplasmosis (can be as short as 3 days) Protozoal
C Chagas’ disease (acute)
C Malaria (Plasmodium falciparum)
C Trypanosoma rhodesiensae
Viral
C CMV, EBV, HIV, viral haemorrhagic fevers

Question 12

Fever in returning travellers: Infections with a long incubation period (>21 days)

Answer 12

Bacterial
C Brucellosis
C Tuberculosis
Fluke
C Schistosomiasis, acute (Katayama fever) Protozoal
C Amoebic liver abscess
C Malaria (including Plasmodium falciparum)

Question 13

Fever in returning travellers:
50 yr old male presented with fever c rigors having returned from a 2/52 holiday in India
No h/o vaccination or prophylaxis Bloods / CXR
Hb : 9.6 , ALT 80 , CRP 110
What bloods ? Differential ?

Answer 13

• P.vivax on smear - Treated with chloroquine - responded well discharged
• G6PD normal
• OP review Primaquine eradication ( 15mg/day)
• 4/12 later - represented c fever to GP - symptomatic treatment • Persistent fever
• Advised rpt Malaria film
• P.vivax again
• Treated with chloroquine - eradication with higher dose Primaquine ( 30mg/day )
• No further recurrence since

Question 14

Fever in returning travellers:
• 18 yr old female, B/bu in UK
• First visit to Nigeria – fever on return
• Vomiting, unwell
• Hb 8.8 , MCV 66, Abnormal LFTs , CRP 45
• Differential

Answer 14

• Admitted – P. falciparum on blood film 2% parasitaemia • Treated c Quinine & Doxycycline
• Completed treatment – no side-effects

Question 15

Fever in returning travellers: How is malaria diagnosed?

Answer 15

National guidelines for Malaria treatment and prevention
• Three negative slides over a period of 48-72 h are necessary to exclude malaria
• Rapid diagnostic tests (RDTs) not a replacement
• All cases of Falciparum malaria should be admitted initially

Question 16

Fever in returning travellers:
• 38 year old female , returned from Pakistan after a 6/52 visit
• 1 week prior to returning had a febrile illness – given some antibiotics locally
• Fever persisted on return – more unwell but no specific symptom/sign
• WCC 3.6 , Hb/Plt – N
• CRP 168 , AST 90, GGT/ Alk Phos 162/136

Answer 16

• Admitted – blood cultures grew S.paratyphi
• Resistant to Ciprofloxacin
• Treated c IV ceftriaxone but fever persisted for 4 days

Question 17

Enteric fever: Management

Answer 17

• Less common but important cause of fever in returning travellers from the sub-continent
• 65-75% isolates can be resistant to Ciprofloxacin – do not use for empirical treatment
• Fever takes a few days to respond – therefore knowing sensitivities is important to persevere with antibiotic to which isolate is sensitive
• Public health implications – microbiological clearance required for certain groups
• including nausea, vomiting and diarrhoea; exquisite severe pain out of proportion to clinical signs due to necrotising fasciitis; a watery vaginal discharge; generalised rash; and conjunctival

Question 18

Fever in returning travellers:
• 28 yr old male banker , presented with 2/52 h/o fever, myalgia and a rash at the beginning of the illness. He had visited Australia 2 months back.
• No focalising signs/symptoms
• Rash resolving , felt unwell but improving
• Bloods : CRP 50

Answer 18

• HIV test : provisional result very low positive • Being sent to Ref lab for more tests
• On further questioning he was gay and had met his new partner 2 months back on the flight back to the UK.
• He had recently tested HIV negative.

Question 19

Fever in returning travellers:
• A VSO worker who had returned from a 1 month stay in Sierra Leone developed fever with shivers, malaise, headache and a sore thoat one week later.
• Presented to A&E
• What would you do ?

Answer 19

• The risk of viral haemorrhagic fevers should be considered in febrile travellers for whom no diagnosis has been made and who become symptomatic within 21 days of leaving known endemic(epidemic ) areas
• Further risk assessment should be done and moderate and high risk cases need to be admitted to HSIDU
• If in doubt, avoid taking non-essential blood tests prior to consulting with infectious disease or microbiology services