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a path 3 > MICRO: Fever in the returning traveller > Flashcards

MICRO: Fever in the returning traveller Flashcards

1
Q
A
  • PVI - presumed viral infection
  • 70% of those returning from Africa had a tropical illness
  • 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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2
Q

Fever and Rash - Dengue, Chikungunya, rickettsial, enteric fever (rose spots), acute HIV, measles

Fever and abdominal pain - Enteric fever, amoebic liver abscess

Undifferentiated fever and normal/ low blood count - Dengue, malaria, rickettsial, enteric, Chikungunya

Fever and haemorrhage - Viral haemorrhagic fevers (dengue and others), meningococcaemia, letposiprosis, rickettsial

Fever and eosinophilia - Acute schistosomiasis, drug hypersensitivity, fascioliasis, other parasitic

Fever and pulmonary infiltrates - Bacterial/ viral pathogens, legionellosis, acute schistosomiasis, Q fever

Fever and altered mental status - Cerebral malaria, viral or bacterial meningoencephalitis, African trypanosomiasis

Mononucleosis syndrome - EBV, CMV, Toxoplasma, acute HIV

Fever persisting >2 weeks - Malaria, enteric fever, EBV, CMV, toxoplasmosis, acute HIV, acute schistosomiasis, brucellosis, TB, Q fever, visceral leishmaniasis (rare)

Fever with onset >6 weeks after travel - vivax malaria, acute hepatitis (B,C,E), TB, amoebic liver abscess

A
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3
Q

RDT = rapid diagnostic test

Malaria paracites look like “headphones”, there are two of them in the cell so it’s more likely falciparum

A
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4
Q

Case 1:

A

High prasitaemia - most helpful for guiding treatment

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5
Q
A

IV artesunate gives 30% reduction in mortality vs IV quinine in severe malaria

NB: 20% means that 20% of erythrocytes have been infected with malaria parasites

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6
Q

What % of African children deaths are caused by Malaria?

A

20%

African child may have 5 episodes of malaria per year affecting growth and development

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7
Q

How many cases of Malaria is seen in the UK per year?

A

~1500

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8
Q

What are the 5 types of Plasmodium species?

A

P. falciparum - MOST SEVERE - increased drug resistance, infects erythrocytes of all stages

P. vivax and P. ovale

P. malariae

P. knowlesi - behaves like falciparum

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9
Q

What is the life cycle of malaria?

A

NB: vivax and ovale have a hypnozoites stage in the liver (parasites are asleep in the liver) so targeted malarials need to be given for that

In humans: erythrocytic and exoerythrocytic stages

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10
Q

Describe techniques for prevention of malaria.

A

Repellants/nets

Prophylaxis - malorone/mefloquine/doxycycline

Take note of region (may recommend different medication by region), individual characteristics (e.g. pregnancy) etc

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11
Q

How does malaria present?

A

Fevers – cyclical or continuous with spikes

Malaria paroxysm – chills, high fever, sweats

Severe Malaria:

  • High parasitaemia* or schizont
  • Altered consciousness with/ without seizures
  • Respiratory distress or ARDS
  • Circulatory collapse
  • Metabolic acidosis
  • Renal failure, haemoglobinuria (blackwater fever)
  • Hepatic failure
  • Coagulopathy +/-DIC
  • Severe anaemia or massive intravascular haemolysis
  • Hypoglycemia
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12
Q

What is a schizont an indication of?

A

Even one schizont indicates a severe malaria

Schizont is a cell with multiple parasites which could burst and cause a rapid rise in parasitaemia

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13
Q

What is the % parasitaemia used in the UK for treatment cut-off?

A

2% is usually the cut-off used in guidelines to treat.

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14
Q

What laboratory tests are used for malaria?

A

Thick and thin blood smears x3

  • Field’s or Giemsa* stain
  • Thick: screen parasites (sensitive)
  • Thin: identify species & quantify parasitaemia

Malaria antigen detection tests

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

*Giemsa for better detection of species

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15
Q

Summarise the management of malaria.

A
  1. Decide whether falciparum or not
  2. If falciparum check if severe or mild
  3. If non-falciparum check for G6PD deficiency
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16
Q

Milf falciparum malaria:

Not vomiting, Parasitaemia <2%, Ambulant = Oral Malarone ™ (atovaquone and proguanil), 4 tablets daily with food for three days

ACT – artemisinin combination therapies =

  • E.g Riamet/ Co-artem – Artemisinin & Lumefantrine,
  • Oral quinine 600mg tds (salt)
  • then doxycycline 100mg od for 1 week
A

Severe falciparum malaria:

  • ABC
  • Correct Hypoglycamia
  • Cautious rehydration (avoid overload)
  • Organ support as necessary

IV Artesunate in preference to IV Quinine

Daily parasitaemia then PO follow on eg with ACT

17
Q

What is a side effect of IV quinine vs artesunate?

A

Artesunate side effects: delayed haemolysis

Quinine side effects: cinchonism, arrhythmias, hyperinsulinaemia

18
Q

Case 2: Some conjunctival injection, travelled abroad to SE Asia, arthralgia, thrombocytopenia,, no anti-malarials but told not needed.

A

Dengue

19
Q
A

Dengue

20
Q
A

Aedes mosquito

21
Q

What type of disease is Dengue caused by? How many serotypes?

A

Flavivirus

4 main serotypes - reinfection can occur and may be worse

Mostly URBAN

22
Q

How common is Dengue in the UK?

A

Seen in ~340/year mostly from SE Asia

23
Q

What is the presentation and onset of Dengue?

A
  • Short incubation
  • Fever, retro-orbital headache, myalgia, erythrodermic rash
  • Severe - bleeding, hepatitis, encephalitis, myocarditis
  • Rash in 50%
24
Q

What is the spectrum of disease in Dengue?

A

Usually mild self-limited illness - mild febrile/ dengue haemorrhagic/ dengue shock.

DHF and shock syndromes rare in travellers - Occur in those previously infected with a different Dengue serotype

25
Q

What is the treatment for Dengue?

A

Supportive only

Identify those at high risk - high Hct, low platelets

26
Q

How do you prevent Dengue?

A

DEET = insecticide

27
Q

What serology is done for Dengue? What PCR can be done?

A

IgM will be positive after 5-7 days - BUT can cross react with IgG for other flaviviruses (JE, yellow fever)

PCR is preferred - may be done on blood or urine

28
Q

“Fever apperance of Himalaya peaks” are characteristic of…?

A

Typhoid fever

Sphygmothermic dissociation (relative bradycardia) in relation to the fever

29
Q

33yo lady born in India, travelled to UK - what is the diagnosis?

  • PC – fever, sweats, constipation, dry cough
  • HPC
  • –Fortnight in India 2/52 prior
  • –Anorexia, 5kg weight loss, diarrhoea before constipation
  • –Confused/ vacant
  • PM – Ix for nephrotic syndrome at HH
  • Examination
  • –T 39 C. 110/70 P=130 Sats 98% RR=30
  • –HS = I+II Gallop rhythm JVP-angle of mandible
  • –Chest – fine bibasal inspiratory creps
  • –Abdomen – mild suprapubic tenderness

•Investigations:

  • –Malaria negative
  • –HIV negative
  • –Blood culture – gram negative rods on day 3

•Management:

  • –Initially ceftriaxone 2g IV OD
  • –Changed to Meropenem at day 3
  • –Careful monitoring and supportive care
A

Typhoid fever

30
Q

What causes typhoid fever?

A

Salmonella typhi or paratyphi

31
Q

How does typhoid fever present?

A

Clinical Presentation:

  • High prolonged fever
  • Headache
  • Rose spots (rare)
  • Constipation
  • Dry cough

Incubation: 7-18 days (up to 60 days)

32
Q

What are the complications of typhoid fever?

A
  • GI bleeding
  • perforation
  • encephalopathy
33
Q

What is the treatment for typhoid fever?

A

Empiric Ceftriaxone (2g IV OD) then Azithromycin (500mg BD 7 days)

34
Q
A

a path 3 (89 decks)

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