Returned traveller

Question 1

Discuss history, examination and ix that should be performed on a returned traveller

Answer 1

HX

• The exact locations, duration and dates of stay including stop-over
• The nature fo the accomodations, use of bed nets and insect repllents
• Vaccination history and adherence to preventative mediacation (malaria)
• Any behaviour that may have led to disease exposure: known insect or tick bites, contact with sick people, animals, fresh water, potentially unsafe food or water and sexual or needle exposure
• History of presenting complaint should include fever patterns and associated symptoms

Exam
-Careful exam from top to toe including cutaneous manifestations, lymph nodes, hepatosplenomegaly and jaundice or bleeding

Question 2

Describe malaria briefly its life cycle

Answer 2

Caused by P, falciparum, p, ovale, p vivax and pmalariae
P.Falciparum is responsible for most cases of mortality associated with malaria

Gametocytes reproduce in the gut of the mosquitoe re injected into the human blood stream and quickly invade the liver. They multiple and are released into the bloodstream and invade erythrocytes. In p/vivax and ovale infection dormant hypnozoites can reside in hepatocytes with infection recurring many months to years later
After invading RBC the merozoites transform into trophozoites which feed on HB in RBCs. THis causes the RBC to undergo lysis releasing merozoites into the blood. Some are destroyed but many others entry new erythrocytes.

Question 3

Discuss clinical features of malaria

Answer 3

Cyclic or irregular fever
-anaemia 
0headache 
-nausea and chills 
-lethargy 
-abdominal pain
-upper respiratory complaints. 

P/falcoparum can cause severe organ system damage and death where as the others do not. Manifestations of acute falciparum infection include

• cerebral malaria
• cerebral oedema
• encephaloapthy
• hypoglycameia
• metabolic acidosis
• severe anaemai
• high output cardiac failure
• renal failure
• pulmonary oedema
• DIC
• death

Question 4

Discuss ix of malaria

Answer 4

Thick and thin blood films

Question 5

Discuss management of maliria

Answer 5

Chloroquine has historically been the treatment of choice for uncomplicated attacks.
Resistance to chloroquine has been steadily increasing
Doxycycline can be used
IV quinine or quinidine

Question 6

Describe Chagas’ disease

Answer 6

Trypanosoma cruzi often lead to acute and chronic myocarditis. Endemic to south and central america. Vector is the reduviid bug that inhabtis the walls and roofs of thached dwelling

Acute infection is hearled by fever facial and dependent extremity oedema hepatosplenomegaly, lymphadenopathy, malaise, lymphocytosis onr peripehral blood smear and eleavted LFTs
-At this stage fatal left ventricular dysfunction and arryhtmias are rare.
Early illness last 1-2 months and resolves spontaneoulsy resulting in a latent period.
IN 25% of caes the infection progresses to chronic CHaga’s disease principally with cardiomyopathy and GI symptoms

Question 7

List travel related infection be incubation period

Answer 7

Short >10 days

• flu
• dengue
• yellow fever
• plague
• paratyphoid
• Mediterranean spotted fever
• Rocky mountain spotted fever

Intermediate 10-21 days

• malaria ( commonest cause of fever in returned travellor 32%, followed by undiagnosed at 25%)
• viral haemorrhagic fevers
• typhoid fever
• scrub tyhpus
• qfever

Long > 21

• malaria
• hepatitis a,b,c,e
• rabies
• shiztosiassis
• filariasis
• brucellosis

Question 8

Discuss an approach to initial management of fever in returned traveller

Answer 8

1) confirm fever
2) Signs of severe sepsis ( confusion, collaps, cyanosis, tachypnoea, hypotension, peritonism, or digital gangrene)
- Resus + blood culture + thick and thin films –> penicillin or ceftriaxone if meningococcal is considered
- urgent admission and isolation

3) No signs of severe sepsis
- History - travel and fever onset
- Pattern of fever - second daily paroxysm in vivax malaria
- focal features - neck stiffness, cellulitis abdominal tenderness, pulmonary consoidation
- investigations - FBC, LFT, Blood cutlure, CXR, Urine MCS,

4) Malaria possible - thick and thin films - if -ve repeat 3 times

5) Rash
- consider dengue or ricketsial disease
- serological test
- consider empirical treatment

6) resp symptoms
- return within 3 days with acute flu symptoms - resp PCR
- pulmonary consolidiation consider atypical pneumonia (legionnaire’s, melioidosis)

7) delayed fever >7 days
- consider enteric fever
- blood stool and urine cultures
- consider empirical quinolone or third gen cephalsporin

8) Jaundice
- acute hepatitis (e.g ABCE, EBC, Q fever) + serological test
- Acute cholangitis
- Liver abscess (amoebic or pyogenic)