INFECTIOUS DISEASE: Traveller with fever/ travel infections Flashcards
Cause of malaria?
Blood protozoan (single celled organism) parasite - Plasmodium species. Spread via bites from female Anopheles mosquito carrying the disease.
Types of Plasmodium species causing malaria?
Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Presentation of malaria - symptoms?
NON SPECIFIC
Abrupt onset rigors
High fever
Sweats
Severe headache
Myalgia
Malaise
Nausea
Vomiting
Main investigation for malaria?
Malaria blood film - need 3 to diagnose malaria
What do blood results for malaria show?
Anaemia
Thrombocytopenia
Leukopenia
Abnormal Liver enzymes
Management for complicated or severe malaria?
(Dr Tom said this is more likely to come up in exam)
Has to be IV:
- Artesunate (most effective, but not licensed)
- Quinine dihydrochloride
- a parasite counts of more than 2% will usually need parenteral treatment irrespective of clinical state
- intravenous artesunate is now recommended by WHO in preference to intravenous quinine
- if parasite count > 10% then exchange transfusion should be considered
- shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse
Complications from malaria by Plasmodium falciparum?
Cerebral malaria
Seizures
Reduced consciousness
AKI —> renal failure
Pulm oedema
DIC - disseminated intravascular coagulopathy
Severe haemolytic anaemia
Death
Blood film for malaria has been done. What other investigations to order?
Rapid antigen test
FBC - haemolysis, low HB, low platelets, thrombocytopenia
U&Es - AKI. high creatinine.
LFTs - ALT, jaundice (pre hepatic)
Glucose - reduced
Coagulation screen
Head CT if CNS symptoms - confusion - can see bleeding or signs of cerebral malaria
CXR - see ARDS
Management for uncomplicated malaria?
Admit P falciparum pts for treatment
Discuss with local ID unit
Oral options as follows:
1 Artemether with lumefantrine (called Riamet)
2 Proguanil and atovaquone (Malarone)
3 Quinine sulphate
4 Doxycycline
Management for complicated or severe malaria?
(Dr Tom said this is more likely to come up in exam)
Has to be IV:
- Artesunate (most effective, but not licensed)
- Quinine dihydrochloride
Main management for malaria with Plasmodium falciparum?
Admit
IV artesunate treatment
Monitor for complications.
Blood film for malaria has been done. What other investigations to order?
Rapid antigen test
FBC - haemolysis, low HB, low platelets, thrombocytopenia
U&Es - AKI. high creatinine.
LFTs - ALT, jaundice (pre hepatic)
Glucose - reduced
Coagulation screen
Head CT if CNS symptoms - confusion - can see bleeding or signs of cerebral malaria
CXR - see ARDS
Malaria prophylaxis advice to give pts?
Know where is high risk
Mosquito spray
Mosquito nets and barriers when sleeping
Antimalarial medication.
What should a travel Hx include about a persons acivity when they return unwell from abroad?
- Countries - stop overs / time
- Activities - lakes (water contact ) / rural backpacking
- water supply - bruhsing teeth / drinking
- Types of Food
- Insect bites - repellent / nets at night
- Accomodation
- Vaccination status / Prophylaxis for malaria taken
- Any symptoms? then or anyone travelling with
- Sexual Hx - condom use/ sex worker/ MSM
- Medical conditons - predispose to infection e.g. diabetes / immunosuppressive therapy
What DDx could a patient traveller coming form aboard have if they describe insect bites?
- Malaria
- Dengue fever
- Leishmaniasis
What DDx could a patient traveller coming form aboard have if they describe Diarrhoea?
- Giardia
- E.coli
- Ameobiasis
- typhoid / para typhoid
- schistomiasis
- tapeworm
What DDx could a patient traveller coming form aboard have if they describe abdominal pain?
- Typhoid / para typhoid
- schistomiasis
- giardia
- amoedbiais
- tapeworm / hookworm / roundworm
What DDx could a patient traveller coming form aboard have if they describe haematemesis?
- Dengue fever
- viral haemorrhagic fever
What DDx could a patient traveller coming form aboard have if they describe urinary symptoms?
- Schistomiasis - urinary freq / dysuria / haematuria
What DDx could a patient traveller coming form aboard have if they describe rigors / high fevers?
- classic for malaria
What DDx could a patient traveller coming form aboard have if they describe night sweats?
- malaria
- TB
- Brucellosis
- Visceral leishmaniasis
What DDx could a patient traveller coming form aboard have if they describe cough?
- Typhoid / paratyphoid
- schistomiasis
- visceral leishmaniasis
What DDx could a patient traveller coming form aboard have if they describe chest pain?
- Typhoid / paratyphoid
Unwell traveller from abroad - what are some differencials if 0-10 days?
- Dengue
- Rickettsia
- Viral (including mononucleosis)
- GI ( bacterial / amoeba)
Unwell traveller from abroad - what are some differencials if 10-21 days?
- Malaria
- Typhoid
- Primary HIV infection
Examinatioin of pt returned from abroad what should you examine the eyes for?
Conjunctival pallor - Anameia:
- Malaria - haemolysis
- Typhoid / paratyphoid
- typhus
Conjunctival Suffusion
- Leptospirosis
Examinatioin of pt returned from abroad and see: jaunice …..what DDx you thinking?
- Malaria
- Hep A - viral hepatitis from food poisoning breakout
Examinatioin of pt returned from abroad and see: ROSE SPOTS (pink macules 2 -3 mm on chest / abdomen) …..what Diagnosis you thinking?
- Typhoid / paratyphoid
Examinatioin of pt returned from abroad and see: crusted ulcer healing by scarring …..what Diagnosis you thinking?
Hallmark of cutaeneous Leishmaniasis
Investigations for pt returned from abroad: what abnormalities are you looking for in a FBC and why might this be?
Haemolytic anaemia :
- Malaria
- Typhoid / paratyphoid
- typhus
Eoisinophilia:
- worm infections
Investigations for pt returned from abroad: what abnormalities are you looking for in a Renal Function U&E and why might this be?
Impaired in:
- Malaria
- Typhus
Investigations for pt returned from abroad: what abnormalities are you looking for in a LFTs and why might this be?
Derranged in:
- Typhoid / paratyphoid
- ameobic abscesses
- schistomiasis
Investigations for pt returned from abroad: what abnormalities are you looking for in a thick and thin blood film ?
3 sets required separate in time
- detect malaria parasite and species
- ring form in Plasmodium falciparum
- Crenulated edge
Investigations for pt returned from abroad: why would you do blood cultures and blood glucose?
- cultures - look for organism
- Glucose - critical in treatment of falciparium as treatment with quinine can cause hypoglycaemia
Investigations for pt returned from abroad: bedside tests might you do?
- urine dip - haemoglobinuria in falciparum malaria
- commericial malaria antigen test kit
What lab required tests might you send off for when investigation a patient returned from abroad ?
- Stool culutes - inclide test for Ova, Cysts and Parasites
- urine specimens for M&S
- Skin lesion biopsy
- Liver biopsy - inflamm response schistomiasis
- lymph node biopsy - leishmaniasis
- Bone marrow cultues -typhoid / paratyphoid / leishmania
Unwell traveller from abroad :
>21 days what are your differencials
- Malaria
- Chronic bacterial (brucella. coxiella, endocarditis, bone and hoint infections)
- TB
- Parasitic infection (helminths / protozoa
Examination of a unwell returned traveller from abroad - black necrotic ulcer with erythematous margins what are you thinking?
Rickettsia (tick exposure)
Examination of unwell returned traveller - what could a maculopapular rash indicate?
Dengue fever
Leptospiroiss
Rickettsia
Infection mononucleosis (EBV, CMV)
childhood : rubella, parovirus B19
primary HIV infection
Examination of unwell returned traveller - what could splenomegaly indicate?
Mononucleosis
Malaria
visceral leishmaniasis
typhoid fecer
brucellosis
What neurological symptoms can you get in a returned traveller who is unwell? How serious is this?
Fever and altered mental state - meningo-encephalitis (EMERGENCY)
e.g. cerebral malaria, Japanese encephalitis, West Nile virus
(also common causes N. meningitis, Strep. pmeumonia, Herpes Simplex virus)
What vaccinications should you ask about in returning traveller who is unwell?
Hep A / B
Typhoid
Tetanus
Childhood vaccines (MMR, yellow fever, rabies)
Treatment for typhoid?
IV ceftriaxone 2g OD (empirical - before sensitivity known)
Once sensitivities known - switch to PO Ciprofloxacin 500mg BD or Azithromycin 500mg OD
Classical definition of Pt with PUO?
Temp 38< (on many occasions)
Illness for 3+ weeks
No diagnosis despite having inpaient investigations for 1+ week
Common causes of Pyrexia with unknown origin?
Infective - TB, abscess, infective endocarditis, brucellosis
AutoImmune/connective tissue - temporal arteritis, Wegener’s granulomatosis
Neoplastic - leukaemias, lymphomas, renal cell carcinoma
Other - drugs, VTE, hyperthyroidism, adrenal insufficiency
What to ask in Hx of Pt with pyrexia of unknown origin?
Chrolonolgy of Sx
Pets/animal exposure?
Travel - in last year?
Occupation?
Meds?
FHx?
Vaccination history?
Sexual contacts?
What to examine in a patient with Pyrexia of unknown origin?
LN? - swollen? where?
Stigmata of endocarditis?
Weight loss/cachexia?
Joint abnormalities?
What investiagtions to do in pt with pyrexia of unknown origin?
Bloods: FBC, U+Es, LFTs, bone profile CRP, clotting, TFTs, MULTIPLE sets of blood cultures (2-3), LDH, B12, ferritin, folate. If you think is related to AI disease = immunoglobulins, RF, ANA, dsDNA etc
Microbiology/virology: HIV, HEP B+C, syphillis, MSU, sputum cultures, malaria films (x3 from 3 diff sites at diff times, for pts w/ travel Hx). Viral swabs, CMV+EBV serology, Brucella serology, fungal serology
Imaging: CXR, CT TAP, MR head, MR spine, PET scan (if relevant)
Biopsies: MC+S, TB culture, histology done on all samples. Need biopsy from bone marrow, LN, abscess, liver
What needs to be monitered when pt is on TB treatment?
LFTs
Visual aquity tests
What is Rickettsial disease?
- occur worldwide and are associated with the patient having been bitten by an ectoparasite such as a louse, mite, flea, mosquito, or most commonly, a tick.
- usually divided into the spotted fever group, where patients present with fever and spots, and the typhus group.
