Posttravel Evaluation Flashcards
what are elements of complete travel history?
hx of present illness;
travel details;
recreational activities;
exposures;
vectorborne disease precautions;
vaccines received;
medications taken;
past medical history;
additional information
what are diseases with slightly longer icubation periods <4-6 weeks?
viral hepatitis
acute HIV
leishmaniasis
malaria
typhoid fever
some infections might become manifest months or even years after a travel returns. what are examples?
leishmaniasis, malaria, schistosomiasis, TB
what are the most frequently dianosed infection from a patient with fevers coming from Asia?
dengue
what are the most frequently dianosed infection from a patient with fevers coming from Africa?
malaria
what are the 3 most common clinical syndromes after travel to low- and middle-income countries ?
dermatologic conditions, diarrheal diseases, and systemic febrile illnesses
what does asymptomatic eosinophilia in a returning traveler suggest?
possible helminth infection;
Allergic diseases, hematologic disorders, and a few other viral, fungal, and protozoan infections also can cause eosinophilia.
Eosinophilia can be present during pulmonary migration of parasites (e.g., Ascaris, hookworm, schistosomiasis, Strongyloides).
lymphatic filariasis, chronic strongyloidiasis, acute trichinellosis, visceral larva migrans
if patnet has delayed illness onset and chronic cough after long-term travel / healthcare worker, what do you suspect?
TB
what are helminths and helminth infections associated with pulmonary symptoms?
Ascaris,
hookworms (Ancylostoma or Necator),
paragonimiasis,
schistosomiasis, and
strongyloidiasis.
what is the disadvantages of antigen rapid test?
less sensitive than nucleic acid testing;
does not provide type or strain information
what are some antigen rapid test available?
dengue; ebola; HIV; influenza; malaria; covid
what are the disadvantage of antibody rapid tetsing?
AB from prior exposure and cross-reactivity limit specificity;
insensitive in acute disease
what are the advantages of AB rapid test?
IgM+ in late-acute/early convalescent phase;
IgG+ in chronic infections or after previous exposure;
Rapid and inexpensive
what are some AB rapid test available?
Dengue, Hep B, Hep C, HIV, Syphilis
what are some Nucleic acid (RNA or DNA) rapid testing available?
Chlamydia, multiple respiratory and GI panels;
Neisseria
covid
what are the advantage of nucleic acid testing?
sensitive and specific in acute phase - can provide quantitative information
if you get negative from rapid antigen tests for influenza or GI pathogens (norovirus, rotavirus), do you still need confirmation test?
yes - with molecular testing
when do you screen dengue for asymptomatic travelers?
kids 9-16 yrs old living in dengue-endemic areas
what is the concern of zika screening?
IgM AB persists months after infection
what do you need to screen when people with relevant exposures of STI from travel?
HIV and syphilis serologic tests,
nucleic acid amplification testing for chlamydia and gonorrhea in urine and at sites of contact (e.g., pharynx, rectum);
HBV testing; hepatitis C virus (HCV) testing;
Test all travelers born between 1945 and 1965 for HCV if not previously tested.
who do you need to screen for stronglyoidiasis?
selectected high-risk with potential skin exposure to human feces, usually a result of a walking barefoot in areas without proper sanitation facilities
when do you need to consider serologic screening in asymptomatic travelers for schistosomiasis?
who bathed or swam in freshwater canals, lakes, or rivers in areas endemic for schistosomiasis.
what screening is preferred for stronglyoides and schistosoma spp?
serologic testing - urine and stool examination lack sensitivity
do you screen asymptomatic possible malaria infection?
no
when do you consider screening for trypanosoma cruzi?
travelers who lived for >6 months in rustic housing (e.g., shelters with mud walls and thatched roofs) in endemic areas of Latin America, especially if they report having seen triatomine bugs inside their dwelling.
consider testing in people who received blood products in an endemic area, or in travelers with clinical manifestations compatible with acute Chagas disease
what are the most common protozoa found in asymptomatic travelers?
is screening recommended?
Blastocystis and Giardia species;
no unless evidence of onward transmission is present
for long-stay (3-6 months) and poor sanitation or hygiene, what are suggested screening tests?
CBC with eosinophil count;
Creatinine
CRP
Liver transaminases
Consider stool ova and parasite
injection or intranasal drug use, medical or dental care, piercing, tattoo - what screen do you suggest after travel?
HBV, if not previously vaccinated (for injection drug use) ;
HCV (for injection or intranasal drug use, unregulated tattoos);
HIV
Pregnant people who traveled in known current Zika virus–endemic or epidemic area or sexual contact with a partner who traveled in these areas, what screening do you recommend?
Screening asymptomatic pregnant travelers who have potential exposure (but without ongoing risk) is not routinely recommended outside an outbreak situation
NAAT ≤12 weeks after potential exposure in endemic or epidemic regions can be considered in pregnant people
Exposure to freshwater rivers, lakes, or irrigation canals - what screening?
schistosoma serology
Walking barefoot on soil potentially contaminated with human feces or sewage - what screening?
strongyloides serology
which malaria species have shorter incubation time <30 days most of the time? which < 30 days after return?
Plasmodium falciparum;
Plasmodium vivax
where are considered tropic areas?
caribbean;
central america;
south america;
south-central Asia;
south-east Asia;
Sub-Saharan Africa;
what are common cause of fever in Caribbean and South America?
Chikung, deng, malaria, zika
what are common cause of fever in Central America?
Caribbean + typhoid or paratyphoid fever
what are the primary malaria species in Central America and South America?
P. vivax
what are common cause of fever in South-Central Asia?
Dengue, malaria (non-P.falciparum),
typhoid or paratyphoid fever
what are common cause of fever in South-East Asia?
Dengue, malaria (non-P.falciparum)
what are common cause of fever in sub-Saharan Africa?
Dengue, Malaria (p. falciparum), tickborne rickettsia (main cause of fever in southern Africa),
acute Schistosomiasis (Katayama fever)
what is the main cause of fever in southern Africa?
Tickborne rickettsia
what are other infections causing outbreaks or clusters of disease among travelers in Caribbean?
Histoplasmosis, acute;
Leptospirosis
what are other infections causing outbreaks or clusters of disease among travelers in Central America?
Coccidioidomycosis;
Histoplasmosis;
Leishmaniasis;
Leptospirosis
what are other infections causing outbreaks or clusters of disease among travelers in South America?
Bartonellosis;
Histoplasmosis;
Leptospirosis;
Yellow fever
what are other infections causing outbreaks or clusters of disease among travelers in Caribbean, Central America, and South America all in common?
leptospirosis
histolasmosis
what are other infections causing outbreaks or clusters of disease among travelers in South Central Asia?
Chikungunya,
Scrub typhus
what are other infections causing outbreaks or clusters of disease among travelers in SouthEast Asia?
Chikungunya
Leptospirosis
which countries are in South Asia?
Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka
which countries are in Central Asia?
Kazakhstan, Kyrgyzstan, Tajikistan, Tukmenistan, Uzebekistan
which countries are in SE Asia?
Indonesia, Vietnam, Laos, Brunei, Thailand, Myanmar, the Philippines, Cambodia, Singapore, Malaysia
which countries are in the Caribbeans?
Antigua, Barbuda, the Bahamas, Barbados, Dominica, the Dominican Republic, Grenada, Guyana, Haiti, Jamaica, Saint Lucia, St. Kitts and Nevis, St. Vincent and the Grenadines, Suriname, Trinidad, Tobago, Puerto Rico
what are 4 main countries in South America?
Brazil, Colombia, Argentina, Peru
what are countries in Central America?
Panama, Costa Rica, Nicaragua, Honduras, El Salvador, Guatemala, Belize
what are other infections causing outbreaks or clusters of disease among travelers in Sub-Saharan Africa?
Chikungunya,
meningococcal meningitis,
trypanosomiasis,
African typhoid or paratyphoid fever
which findings are telling you urgent attention?
hemorrhage, low blood pressure, altered consciousness, high respiratory rate
if a patient has fever and abdominal pain, what infections do you suspect?
typhoid or paratyphoid fever;
liver abscess (amebic or pyogenic)
if a patient has fever and altered mental status or CNS involvement, what infections do you suspect?
meningococcal meningitis, scrub typhus;
arboviral encephalitis (JE, WNV);
Rabies;
Tick-borne encephalitis
angiostrongyliasis, malaria, African cerebral trypanosomiasis
if a patient has fever and arthralgia or myalgia, what infections do you suspect?
chikungunya, dengue, ross river virus, zika;
sarcocystosis, muscular Trichinellosis
if a patient has fever and eosinophilia, what infections do you suspect?
angiostrongyliasis, fascioliasis, sarcocystosis,
schistosomiasis, acute Trichinellosis, other parasites;
drug hypersensitivity reaction
if a patient has fever which has onset after more than 6 weeks of travel, what infections do you suspect?
meliodosis, tuberculosis;
acute hepatitis B, C, E;
Amebic Liver abscess;
malaria (Plasmodium ovale, P. vivax);
African Trypanosomiasis
if a patient has fever which is persistent for more than 2 weeks, what infections do you suspect?
brucellosis, Q fever, TB, Typhoid or paratyphoid fever;
Cytomegalovirus, Epstein-Barr virus, acute HIV;
Leishmaniasis;
Malaria;
acute Schistosomiasis;
Toxoplasmosis
if a patient has fever and hemorrhage, what infections do you suspect?
Leptospirosis, meningococcemia, Rickettsial infections (spotted fever group)
Viral hemorrhagic fevers (e.g. dengue, Ebola, Lassa, YF)
if a patient has fever and mononucleosis syndrome, what infections do you suspect?
cytomegalovirus, Epstein-Barr virus, acute HIV;
toxoplasmosis
if a patient has fever and normal or low white blood cell count, what infections do you suspect?
rickettsial infections, typhoid or paratyphoid fever;
chikingunya, dengue, acute HIV, zika;
malaria
if a patient has fever and rash, what infections do you suspect?
meningococcemia, rickettsial infections (spotted fever or typhus group), typhoid or paratyphoid fever (rash may be sparse-absent);
chikungunya, dengue, acute HIV, measles, varicella, zika
if a patient has fever and respiratory symptoms and pulmonary infiltrates, what infections do you suspect?
legionellosis, leptospirosis, melioidosis, pneumonic plague, penumococcus and other common bacterial respiratory pathogens, Psittacosis, Q fever, TB;
coronavirus, influenza, other common viral respiratory pathogens;
acute schistosomiasis;
acute coccidioidomycosis, acute histoplasmosis
– is the most common cause of febrile illness among people who seek medical care after travel to Latin America or Asia.
Dengue
what are the examples of viral hemorrhagic fevers other than dengue that are important to identify but rare in travelers?
Ebola, Lassa fever, Marburg hemorrhagic fever
— is the most common cause of acute undifferentiated fever after travel to sub-Saharan Africa and some other tropical areas.
malaria
Globally, the emergence and spread of resistance have been linked to …
widespread use of antimicrobials in agriculture and in animal (veterinary) and human health care. Inadequate sanitation and water purification infrastructure also plays a role.
Bacterial colonization of the intestine is influenced and facilitated by …
person’s diet; their use of agents that disrupt normal microbial flora (e.g., antacids, antibiotics); and their interactions with animals, other humans, and the environment.
Enteric bacteria that commonly inhabit the human intestine are?
E. coli, Klebsiella pneumoniae
who are more likely to become colonized with resistant bacteria during travel?
People with comorbidities (e.g., chronic bowel disease);
Consuming foods prepared by street vendors, taking antibiotics during travel, and having travelers’ diarrhea have all been associated with intestinal colonization with antibiotic-resistant bacteria.
Studies have identified that travelers returning from which countries are at risk for colonization with bacteria resistant to extended-spectrum cephalosporins?
countries in East Africa, northern Africa, South America, South Asia, Southeast Asia, and the Middle East
colonization with bacteria resistant to extended-spectrum cephalosporins - risk for acquisition was greatest in which countries?
India, Peru, and Vietnam
Acquisition of carbapenem-resistant Enterobacterales (CRE) has been reported in travelers returning from ?
South Asia and Southeast Asia.
Colonization with E. coli carrying a novel gene that confers colistin resistance has been reported in travelers returning from which countries?
northwest Africa, South America and the Caribbean, East and Southeast Asia, Europe, and the Middle East
In a study of 412 US international travelers, the rate of acquisition of bacteria with the mobile colistin resistance (mcr) gene was ≈ %?
mcr genes are often found in — Enterobacterales.
5
extended-spectrum β-lactamase (ESBL)–producing
which bacteria inactivate all or nearly all β-lactam antibiotics and are often highly antibiotic-resistant, making them difficult to treat?
Carbapenemase-producing bacteria
carbapenemase production is the more frequent mechanism of carbapenem resistance, especially for which species?
Pseudomonas aeruginosa.
Around the world, which is the most common carbapenemase?
New Delhi Metallo-β-lactamase (NDM)
Antimicrobial-resistant gram-positive bacteria are a major cause of health care–associated infections. what are they?
Methicillin-resistant Staphylococcus aureus;
vancomycin-resistant enterococci (VRE);
Transmissible linezolid resistance has been identified in gram-positive bacilli, including which species from several countries worldwide, particularly in South America?
Transmissible linezolid resistance has been identified in gram-positive bacilli, including S. aureus, coagulase-negative Staphylococcus, and Enterococcus spp. from several countries worldwide, particularly in South America.
which is distinct from other Candida species because it tends to cause outbreaks in health care facilities, can result in long-term asymptomatic skin colonization, persists in health care environments, and has high levels of resistance to multiple classes of antifungal agents?
Candida auris
what are sources of AB-resistant enteric bacteria?
foods and food animals, water, insects (e.g. flies)
For patients admitted to health care facilities in the United States after hospitalization in facilities outside the United States within the past 6 months, consider which screening?
rectal screening to detect Carbapenem-Resistant Enterobacterales colonization;
Consider screening for which colonization in patients who have had an overnight stay in a health care facility outside the United States in the previous 12 months?
Candida auris
Bacterial causes of respiratory illnesses include …
Bordetella pertussis,
Burkholderia pseudomallei,
Chlamydophila pneumoniae,
Corynebacterium diphtheriae,
Haemophilus influenzae,
Mycoplasma pneumoniae, and
Streptococcus pneumoniae.
which species can cause outbreaks and sporadic cases of respiratory illness?
Coxiella burnetii and Legionella pneumophila
Viral pathogens are the most common cause of respiratory infection in travelers. Causative agents include which viruses?
adenoviruses,
coronaviruses,
human metapneumovirus,
influenza virus,
measles, mumps,
parainfluenza virus,
respiratory syncytial virus, and
rhinoviruses.
Other viruses of special concern for respiratory infection to travelers include which viruses?
Consider these viruses in travelers with new-onset respiratory illness, including people requiring hospitalization, when no alternative cause has been identified.
Middle East respiratory syndrome (MERS) coronavirus and highly pathogenic avian influenza viruses;
patient develops fever and pneumonia ≤14 days after traveling from countries in or near the Arabian Peninsula. what can you suspect?
MERS
patients with new onset of severe acute respiratory illness requiring hospitalization when no alternative cause has been identified. A history of recent (≤10 days) travel to a country with confirmed human or animal cases—especially if the traveler had contact with poultry or sick or dead birds—increases the likelihood of the diagnosis
Avian influenza virus
Fungal pathogens associated with respiratory infection and travel include?
Blastomyces dermatitidis,
Coccidioides spp.,
Cryptococcus gattii,
Histoplasma capsulatum
Paracoccidioides spp.,
Talaromyces marneffei (formerly Penicillium marneffei)
what chemical exposures are associated with health risks including respiratory tract inflammation, exacerbation of asthma or COPD, impaired lung function, bronchitis, and pneumonia?
carbon monoxide, nitrogen dioxide, ozone, sulfur dioxide, and particulate matter
Consider which disease in the differential diagnosis of travelers who present with cough, dyspnea, tachycardia, or fever and pleurisy, especially those who have recently been on long car or plane rides or who were recently infected with SARS-CoV-2.
Pulmonary embolism
if the traveler has a preexisting eustachian tube dysfunction, using a which immediately before air travel, which might decrease the likelihood of otitis or barotrauma.
vasoconstricting nasal spray
The pathogenesis of persistent diarrhea in returned travelers generally falls into one of the following broad categories:
ongoing infection or co-infection with a second organism not targeted by initial therapy;
previously undiagnosed GI disease unmasked by the enteric infection; or
a postinfectious phenomenon.
which–associated diarrhea can occur after treatment of a bacterial pathogen with a fluoroquinolone or other antibiotic, or after malaria chemoprophylaxis.
Clostridioides difficile
patients with persistent TD that seems refractory to multiple courses of empiric antibiotic therapy - what can you suspect?
Clostridioides difficile
what is the treatment for C. diff?
Clinicians can prescribe oral vancomycin, fidaxomicin, or, less optimally, metronidazole to treat C. difficile.
patients with upper GI–predominant symptoms for prolonged time - what can you suspect?
Giardia
Rare causes of persistent symptoms include the intestinal parasites … ?
Cystoisospora,
Dientamoeba fragilis, and
Microsporidia.
what is associated with deficiencies of vitamins absorbed in the proximal and distal small bowel and most commonly affects long-term travelers to tropical areas, as the name implies?
tropical sprue
what is a syndrome of acute onset of watery diarrhea lasting ≥4 weeks. Symptoms include 10–20 episodes of explosive, watery diarrhea per day, fecal incontinence, abdominal cramping, gas, and fatigue. Nausea, vomiting, and fever are rare?
Brainerd diarrhea
what are other underlying GI diseases that can cause diarrhea?
celiac disease
colorectal cancer
inflammatory bowel disease
what are the most common skin problems identified during posttravel medical visits?
1 cutaneous larva migrans,
2 inset bite reactions,
3 skin abscess, bacterial infections
Consider what infections in the differential diagnosis of febrile travelers with rashes?
cytomegalovirus,
enteroviruses (e.g., coxsackievirus, echovirus),
Epstein-Barr virus,
hepatitis B virus,
histoplasmosis,
leptospirosis,
measles,
syphilis, and
typhus
what are systemic viral infections associated with fever and rash?
Chikung,
Dengue,
Zika,
acute HIV,
what are systemic bacterial infections associated with fever and rash?
Meningococcemia - petechiae that often expand into purpuric macules and patches;
Rickettsiosses - African Tick-Bite fever (Rickettsia africae) - frequent cause of fever and rash in southern Arica;
Rocky mountain spotted fever - rash on the ankles and wrists and spreads centrally and to the palms and soles, rash commonly starts as a blanching maculopapular eruption that becomes petechial;
what are common organisms responsbiel for bacterial skin infection?
Staphylococcus aureus and Streptococcus pyogenes.
A deeper lesion that resembles urticarial patches and that progresses rapidly might be due to larva currens (running larva), caused by cutaneous migration of filariform larva of ..?
Strongyloides stercoralis
what screening tests are done for immigrants?
testing for gonorrhea (by nucleic acid amplification),
testing for syphilis (by serology), and
tuberculosis (TB) screening.
Immigrants & nonrefugee migrants to the United States: recommended new arrival infectious disease screening?
CBC with differential;
HBsAg (home country hep B infection prevalence >2%);
Hep C - 18-79 years;
HIV >13 years;
Malaria - all if signs or symptoms and migration route includes malaria-endemic areas;
Parasite serology - Schisto, Strong, Soil-trans helminths - all if from endemic country;
STI - 15-65 years;
TB - IGRA 2 years and up; TST <2 years;
Urinalysis - all if clinically indicated
Immigrants & nonrefugee migrants to the United States: recommended new arrival toxic & metabolic screening?
Blood lead level - < 16 years or people who are pregnant or lactating if they are clinically indicated;
CBC with differential + MCV;
Urinalysis
which are among the most common infectious diseases reported worldwide. In 2018, ≈26 million new cases were reported in the United States; and in 2016, ≈376 million cases were reported globally.
STI - chlamydia, gonorrhea, syphilis, trichomonas
Assessing risk in men who have sex with men (MSM) is important because they have elevated rates of certain infections, including …
hlamydia, gonorrhea, lymphogranuloma venereum, and syphilis
what are some bacterial STIs and species causing it
Chancroid - Haemophilus ducreyi;
Chlamydia - Chlamydia trachomatis;
Gonorrhea - Neisseria gonorrhoeae;
Granuloma inguinale (donovanosis) - Klebsiella granulomatis;
Lymphogranuloma venereum - Chlamydia trachomatis serovar L1-3;
Syphilis - Treponema pallidum
what are some viral STIs?
Hep A, B, C
Herpes simplex virus (HSV)
Genital warts - Human papilloma virus (HPV)
what is the treatment for Herpes simplex virus?
Acyclovir 400mg tid for 7-10 days;
valacyclovir 1g bid for 7-10 days;
famciclovir 250mg tid for 7-10 days
what is the treatment for Lymphogranuloma venereum (Chlamydia trachomatis serovar L1-3)?
doxycycline 100mg bid for 21 days
what is the treatment for granuloma inguinale (donovano sis) caused by Klebsiella granuloatis?
azithromycin 1g weekly for 3 weeks or until resolution; or
azithromycine 500mg daily for 3 weeks or until resolution
what is the treatment for gonorrhea - Neisseria gonorrhoeae?
cetriaxone 500mg IM x1
what is the treatment for chlamydia?
doxycycline 100mg bid for 7 days;
azithromycin 1g stat
what is the treatment for Chancroid (Haemophilus ducreyi)?
azithromycine 1g stat, or
cefriaxone 259mg IM stat;
ciprofloxacin 500mg bid for 3 days;
erythromycin base 500mg tid for 7 days
where is Chancroid geographic distribution?
Africa, Asia, Caribbean
where is granuloma inguinale found?
Souther Africa, Australia, India, Papua New Guinea
what is parasitie STI?
how do you treat it?
Trichomoniasis - trichomonas vaginalis;
metronidazole 500mg bid for 7 days (female);
2g stat (male) or tinidazole 2g stat (female&male)
